Advanced Spinal Canal Decompression Procedures

A 34 year old male patient presented to my office for a second opinion after undergoing a TLIF at an outside facility one year ago. He had been told that “nothing was wrong,” but his pain never improved. After listening to his concerns, we obtained new imaging studies, which showed several significant issues. There was a pseudoarthrosis—meaning the bones never fused—and the TLIF cage had migrated (or was inadvertently placed) into the spinal canal. The pedicle screws were also malpositioned, including screws placed into the disc space and neural foramen. These findings explained his continued pain and neurologic symptoms. An EMG done preoperatively revealed an acute L5 radiculopathy. Given the severity and location of the problems, I offered surgical intervention. We approached this using a “back–front–back” reconstruction. We revised the screws, removed the migrated TLIF cage through an anterior approach, and performed an ALIF to restore alignment and stability. There was no osseous union at the prior level, confirming that the original fusion never healed. The goal of the reconstruction was to decompress the nerves, correct the hardware issues, restore disc height, and finally achieve a solid fusion so he could return to normal quality of life. ALIF procedures have several advantages over TLIFs in select patients. ALIFs allow for more complete disc space preparation, placement of larger interbody cages, and better restoration of lumbar lordosis and foraminal height. The anterior approach also avoids working around the nerves, reducing the risk of nerve retraction injury compared to a posterior approach. This often allows for improved fusion rates and more predictable alignment correction. TLIFs can be excellent procedures when performed accurately, but they also carry potential downsides. Because the surgery is done through the back, the working space is narrow, and the nerves must be retracted to place the cage. Improper visualization can lead to complications such as malpositioned pedicle screws, cages entering the canal, violation of the foramen or disc space, and incomplete disc preparation that increases the risk of pseudoarthrosis. These complications are exactly how this patient presented—persistent symptoms, hardware in the wrong place, and a fusion that never healed. This case is a reminder that persistent pain after spine surgery should never be ignored. A second opinion can be critical, especially when symptoms don’t match what a patient is being told. As surgeons, our job is not just to operate—it is to listen, evaluate carefully, and help patients understand all their options so they can make informed decisions about their spine health. www.antoniowebbmd.com

At the 2024 AANS/CNS Section on Disorders of the Spine and Peripheral Nerves Juan Uribe, MD posed a challenge: he wanted to see an endoscopic approach successfully decompress a calcified thoracic disc herniation on post-op imaging before he would believe it possible… Challenge accepted. Check out this follow up to the thoracic disc herniation case I presented last week. Using a right T7-8 transforaminal endoscopic discectomy approach with a slightly modified rostral to caudal angle of attack, I was able to remove the more than 1cm calcified fragment from the ventral canal all while avoiding the T8 pedicle screw. The post-op CT scan shows the successful outcome, with complete ventral decompression achieved well across midline. Notably, the patient was discharged on POD#1 without any need for narcotics. #futureofspinesurgery #endoscopicspinesurgery #narcoticfreespinesurgery #minimallyinvasivespinesurgery

In my practice at the University of Washington, full-endoscopic cervical ULBD has largely replaced laminoplasty for carefully selected patients. 📊 What our study with Osama Nezar Kashlan, MD MPH and John O. shows: • Mean age ~70 years • Blood loss ~10 mL • ~90 min per level • Outpatient surgery - Symptomatic improvement and well tolerated even in older patients ⚠️ But also important: • ~12% developed new neurological deficits • All occurred in severe (Grade 3) stenosis • Risk strongly correlated with sustained MEP loss at closure Take-home: This is a procedure for the expert endoscopic surgeon. Not every pathology is suitable Technical shortcuts get punished. #ESRG, #iSERF, #Endospine #MISS

A rare but known cause of dysphagia in middle age patients is massive cervical anterior osteophytes - particularly in the upper mid cervical #spine at C3/4 and C4/5. Often the remaining mobile segments are very degenerative and significant stenosis can co-exist. There can be features of Diffuse Idiopathic Skeletal Hyperostosis throughout the spine. This mid-60s male presented with progressive severe dysphagia after referral from an #ENT surgery colleague. He had minimal axial neck pain and no radicular pain but did note a gradual loss of upper and lower limb coordination. Imaging showed severe bony osteophyte formation at C4/5, obstructing normal contrast flow on Barium swallow. In addition he had significant C3/4 Stenosis on MRI. We decided to anteriorly debride C4/5 and perform an ACDF with spinal cord decompression and integrated cage at C3/4. Pre and post operative pharyngoscopy confirmed decompression. Bone surfaces were sealed with bone wax and a drain placed. I often use the o-arm to confirm adequate resection. He did require an NG tube for post-operative swallowing issues that resolved over 4 days. I find this relatively common despite drains and dexamethasone coverage. At 2 years post-operative his presenting symptoms have improved by >90%. He has no further myelopathic symptoms or signs. His CT scan at 2 years is demonstrated in the last 2 images. Take home lessons 1. Although a rare cause of dysphagia I would see 1-2 cases requiring surgical Rx every year 2. Usually the main obstruction is at C3/4 or C4/5 3. The osteophyte pattern is highly variable. Intra-operative 3D imaging can be helpful 4. Pharyngeal visualization pre and post surgery is helpful 5. Post-operative swallowing issues can occur due to oedema and the bleeding from bone resection but usually resolve quickly 6. Concurrent cervical stenosis is common #spinesurgery #neurosurgery #orthopaedics #orthopedicsurgery

𝗖𝗵𝗼𝗼𝘀𝗶𝗻𝗴 𝘁𝗵𝗲 𝗥𝗶𝗴𝗵𝘁 𝗔𝗽𝗽𝗿𝗼𝗮𝗰𝗵 𝗠𝗮𝘁𝘁𝗲𝗿𝘀 Recently I operated on a patient with an L3 L4 up migrated lumbar disc herniation. The extruded fragment was causing excruciating anterior thigh pain on the left side. At first glance there were multiple options to consider. 1. An interlaminar ipsilateral approach carried the risk of an iatrogenic pars fracture which could have led to the need for a fusion. 2.A contralateral sublaminar approach from right to left although I enjoy right sided approaches would have meant exposing the entire dural sac along with the traversing and exiting roots. This could have predisposed the patient to fibrosis in the future. 3. I chose the ipsilateral para UBE or extra foraminal UBE approach. With minimum bony work and careful soft tissue handling I could directly visualize the exiting root navigate underneath the traversing root and dura and remove the extruded fragment. The outcome was effective decompression with preservation of stability and less collateral exposure. Surgery is not only about technique it is about choosing the most appropriate strategy for the patients long term outcome. What would you have done ? AO Spine Jin-Sung (LUKE) Kim Dimitrios Eduardo Joseph François Ariel Elsa Xavier Jose Prof Constantin Schizas FRCS Nicolas Stefan Kern Singh Sérgio Alfredo European Society of Unilateral Biportal Endoscopy (ESUBE) Nexon Medical International Society for Minimally Invasive Spine Surgery (SMISS) #UBE #SpineSurgery #MinimallyInvasiveSpineSurgery #BiportalEndoscopy

Revision Spine Strategy: ALIF vs MIS TLIF with Expandable Cage — Restoring Lordosis & Global Sagittal Balance A patient with a history of L4–L5 TLIF done 10 years ago presented with progressive symptoms and segmental degeneration at L5–S1. The key surgical goals were clear: ✔ Restore segmental lordosis at L5–S1 ✔ Improve overall Global Sagittal Balance ✔ Achieve solid anterior column support ✔ Avoid unnecessary morbidity in a revision spine In such cases, the decision often revolves around: ALIF (Anterior Lumbar Interbody Fusion) vs MIS TLIF with Expandable Cage Both aim to reconstruct the anterior column — but through fundamentally different biomechanical strategies. ALIF remains powerful when maximal segmental correction is required, especially in major sagittal imbalance cases. MIS TLIF with Expandable Cage — Posterior Precision with Alignment Control In this case, we chose L5–S1 MIS TLIF using a Medtronic expandable cage. Why? Because modern expandable technology allows us to: ✔ Insert the cage in a collapsed profile ✔ Expand in situ to restore disc height ✔ Achieve meaningful segmental lordosis from a posterior-only approach ✔ Avoid anterior vascular exposure ✔ Work efficiently in a previously operated spine The Medtronic expandable cage provides controlled anterior column expansion, enabling: • Restoration of foraminal height • Indirect decompression • Segmental lordosis improvement • Strong anterior column load sharing In revision scenarios — especially below a prior fusion — maintaining a posterior corridor can be strategically advantageous. The evolution of expandable cages has significantly narrowed the historical lordosis gap between ALIF and TLIF. The Bigger Picture: Global Sagittal Balance At L5–S1, segmental lordosis plays a disproportionate role in: • Pelvic incidence–lumbar lordosis (PI–LL) matching • Sagittal vertical axis correction • Long-term adjacent segment protection In this patient with prior L4–L5 fusion, restoring L5–S1 lordosis was critical to protect the construct above and optimize global alignment. A posterior MIS strategy with an expandable cage allowed us to achieve alignment goals while minimizing approach-related morbidity. Technology does not replace judgment — it enhances it. The real question is not ALIF vs TLIF. The real question is: 👉 What does this patient’s alignment demand? 👉 What is the safest corridor in this specific spine? 👉 How do we achieve durable biomechanics with minimal collateral damage? Modern spine surgery is no longer about access. It is about precision alignment. #SpineSurgery #MISSpine #TLIF #ALIF #SagittalBalance #LumbarFusion #RevisionSpine #Medtronic #GlobalAlignment

“In thoracic disc surgery, the difference between success and paralysis can be just a few millimeters.” Giant calcified thoracic disc herniations remain one of the most unforgiving problems we face in spine surgery. The images below show a recent case with severe spinal cord compression pre-operatively and complete decompression after surgery. For these lesions, the retropleural approach has become my workhorse technique. It allows safe anterior access to the pathology while minimizing spinal cord manipulation and enabling a controlled, complete resection of the calcified disc. Importantly, the retropleural corridor is still considered a minimally invasive approach, particularly when compared with the traditional thoracotomy procedures historically required to treat thoracic discs. I strongly believe in the value of endoscopic spine surgery, and it is clearly transforming many areas of spine care. However, after performing both techniques, my experience remains that giant calcified thoracic discs are still best managed through a retropleural approach. In these operations the priorities must be absolutely clear: • Complete decompression of the spinal cord • Direct visualization of the pathology • Zero tolerance for neurological complications When the risk of paralysis is real, the surgical strategy must prioritize safety and complete decompression above everything else. New technologies are exciting, but not every pathology should be forced into the newest technique. Curious to hear how others are approaching giant calcified thoracic discs Barrow Neurological Institute AANS/CNS Section on Disorders of the Spine and Peripheral Nerves ATEC Spine joimax Society for Minimally Invasive Spine Surgery (SMISS) ISASS: The International Society for Advancement of Spine Surgery