Marcelo Botelho Soares de Brito

Minimally invasive endoscopic surgery of the lumbar spine has transformed the way degenerative disorders of this segment are understood and treated. However, the technological advances associated with this modality have required surgeons to face a new and challenging learning curve. Among the technical aspects, the transforaminal endoscopic lumbar access has stood out due to the complexity of disc puncture, a critical step for procedural success. During training, this phase has represented one of the main barriers to skill acquisition, and the accumulation of unsuccessful attempts has been a determining factor for withdrawal among many surgeons. In this context, an alternative technique based on osseous landmarks was proposed, using an oblique biplanar access, aiming to improve positional safety during disc puncture and to provide greater predictability for surgeons in the early stages of training in this approach. Level of Evidence IV;Technique Description and Case Report.

Minimally invasive spine surgery has achieved remarkable advances in recent years. Despite the numerous benefits associated with this approach, some complications may still occur. Among them, the use of continuous irrigation in the epidural space stands out, as it can cause changes in intracranial pressure (ICP). The present study aims to conduct a systematic review of the literature on ICP variations during endoscopic lumbar spine surgery. To this end, a search was carried out in the PubMed, Embase, Scielo, Lilacs, and Google Scholar databases, selecting studies that evaluated ICP intraoperatively during endoscopic spine procedures. Five comparative studies were included: three measured epidural pressure as an indirect surrogate of intracranial pressure (ICP), whereas two performed direct ICP measurements. Three of these studies identified significant changes in ICP during the procedure, whereas two did not observe relevant fluctuations. The analysis of the literature therefore confirms the possibility of ICP variations occurring intraoperatively in endoscopic lumbar spine surgeries. Level of Evidence III; Systematic Review.

This study investigates the relevance of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of root compressions of bony or calcified origin, considering the challenges imposed by the multifactorial etiology of sciatica. The research also reviews advances in understanding the discogenic and non-discogenic causes of the condition, in addition to discussing the limitations of the clinical evaluation of dermatomes, often marked by overlaps and anatomical variability. The analysis of a clinical case involving a 59-year-old patient with left-sided lumbosciatic pain allowed a precise correlation between clinical and radiological findings, highlighting the importance of an integrated diagnostic approach. Computed tomography revealed the presence of a calcified juxtafacet cyst and marginal osteophytes, both directly contributing to root compression. In contrast, MRI was limited in fully elucidating the etiology. Surgical treatment, performed via transforaminal endoscopic approach, resulted in complete symptom relief, significant functional improvement, and early return to daily activities. The findings of this study reinforce the complementary role of imaging techniques in the diagnosis of sciatica and suggest a more careful evaluation of dermatomes in the clinical setting. The adoption of multimodal approaches contributes to greater diagnostic accuracy and therapeutic efficacy, promoting better clinical outcomes for patients affected by radicular syndromes. Level of Evidence III; Review Article.

Minimally invasive surgery (MIS) has gained prominence in the treatment of lumbar spinal stenosis (LSS), especially with the advancement of uniportal (UE) and biportal (UBE) endoscopic techniques. Both seek to reduce surgical trauma without compromising decompression efficacy, although they have distinct characteristics that influence their choice. This study compared UE and UBE through a systematic review and meta-analysis. Databases such as PubMed, Google Scholar, Ovid, and BVS were analyzed. Data were organized in Excel and processed in R software (v4.2) with the meta package. Continuous variables were expressed as mean differences (MD) and categorical variables as odds ratios (OR). Heterogeneity was assessed by Cochran’s Q and chi-square tests (p < 0.05). Random or fixed-effects models were applied depending on heterogeneity. Of the 164 studies initially identified, 15 were selected for full reading and 8 were included in the final analysis. There was no statistically significant difference between the techniques in the outcomes evaluated, except for the ODI score at the last follow-up, where UBE showed slightly lower values. However, this difference (MD = 0.54) was not clinically relevant. Both endoscopic techniques are effective and safe for lumbar decompression in cases of stenosis, with no statistical superiority between them. Level of Evidence III; Systematic Review.

Introduction and objective: Endoscopic decompression has emerged as an effective and minimally invasive therapeutic alternative for the management of adjacent-level stenosis in patients previously undergoing lumbar fusion. This condition, known as Adjacent Segment Disease (ASD), often manifests years after the surgical procedure, with clinical symptoms such as sciatica, neurogenic claudication, and progressive functional impairment. This study presents a series of clinical cases investigating the results of the endoscopic approach in patients diagnosed with foraminal and central stenosis at a single level adjacent to fusion. Methods: The fully endoscopic technique used allows direct access to the stenosed area with minimal aggression to surrounding tissues, promoting effective neural decompression, reduced perioperative morbidity, and accelerated recovery. Results and conclusion: Preliminary results suggest that endoscopic decompression may represent a viable and advantageous strategy compared to conventional approaches, especially in patients at high surgical risk or seeking less invasive options. Level of Evidence IV; Case Series.

Objective: To evaluate the surgical and postoperative outcomes of patients undergoing reverse foraminoplasty via a contralateral endoscopic approach for the treatment of central canal or lateral recess stenosis associated with foraminal stenosis, with a minimum follow-up of two years. Methods: This retrospective, quantitative, and descriptive study was conducted at Porto Dias Hospital, Belém-PA, and approved by the Research Ethics Committee. Thirteen patients who met the inclusion criteria were enrolled. Primary outcomes included pain reduction, assessed by the Visual Analogue Scale (VAS), and functional improvement, measured by the Oswestry Disability Index (ODI). Data normality was tested using the Shapiro-Wilk test, and paired t-tests were used to compare outcomes over time (significance level p < 0.05). Results: The mean patient age was 57.3 ± 13.54 years. The average operative time per level treated was 58.4 minutes (range: 22-117 min). There was a mean ODI reduction of 33.6 points over the follow-up period (p < 0.001). Local pain (VAS) decreased from 6.8 to 1.8, and radicular pain from 7.9 to 1.6 after two years (p < 0.001 for both). One complication was reported (dural tear; 7.69%). Conclusions: Reverse foraminoplasty performed via a contralateral endoscopic approach was safe and effective, providing sustained pain relief, significant functional improvement, and a low complication rate over a two-year follow-up. Level of Evidence III; Retrospective Comparative Study.

Background Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT) code 62380. However, no work relative value units (RVUs) are currently assigned to the procedure. An international team of endoscopic spine surgeons conducted a study, endorsed by several spine societies, analyzing the learning curve, difficulty, psychological intensity, and estimated work RVUs of endoscopic lumbar spinal decompression compared with other common lumbar spine surgeries. Methods A survey comparing CPT 62380 to 10 other comparator CPT codes reflective of common spine surgeries was developed to assess the work RVUs in terms of learning curve, difficulty, psychological intensity, and work effort using a paired Rasch method. Results The survey was sent to 542 spine specialists. Of 322 respondents, 150 completed the survey for a 43.1% completion rate. Rasch analysis of the submitted responses statistically corroborated common knowledge that the learning curve with lumbar endoscopic spinal surgery is steeper and more complex than with traditional translaminar lumbar decompression surgeries. It also showed that the psychological stress and mental and work effort with the lumbar endoscopic decompression surgery were perceived to be higher by responding spine surgeons compared with posterior comparator decompression and fusion surgeries and even posterior interbody and posterolateral fusion surgeries. The regression analysis of work effort vs procedural difficulty showed the real-world evaluation of the lumbar endoscopic decompression surgery described in CPT code 62380 with a calculated work RVU of 18.2464. Conclusion The Rasch analysis suggested the valuation for the endoscopic lumbar decompression surgery should be higher than for standard lumbar surgeries: 111.1% of the laminectomy with exploration and/or decompression of spinal cord and/or cauda equina (CPT 63005), 118.71% of the laminectomy code (CPT 63047), which includes foraminotomy and facetectomy, 152.1% of the hemilaminectomy code (CPT 63030), and 259.55% of the interlaminar or interspinous process stabilization/distraction without decompression code (CPT 22869). This research methodology was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the Mexican Society of Spinal Surgeons (AMCICO), the International Society For Minimally Invasive Spine Surgery (ISMISS), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Surgery (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS). Clinical Relevance This study provides an updated reimbursement recommendation for endoscopic spine surgery. Level of Evidence Level 3.

We describe the use of an endoscopic approach to fix a pars interarticularis defect in a 33-yearold man with a 7-year history of refractory low back pain, whose case had been previously diagnosed as spondylolysis. The advantage of using this technique lies in minimum muscle trauma, since it only requires a single 6-mm transverse incision. Neither intraoperative nor postoperative complications were observed. The patient reported nocturnal pain improvement and presented favourable clinical recovery after 3.5 years of follow-up. He recorded an 8% Oswestry Disability Index and visual analogue scale scores of 2 and 0 for low back and lower-limb pain, respectively. Therefore, the endoscopic technique described herein is a feasible approach to treating spondylolysis.

Cervical endoscopy is one of the most advanced stages in the learning curve for endoscopic techniques in spine surgery, requiring precise control of instruments to avoid severe complications. We report the case of a 53-year-old female patient with bilateral cervicobrachialgia and myelopathy caused by severe central stenosis at C2-C3. After the failure of conservative treatment, an endoscopic posterior over-the-top cervical decompression was performed. The surgery was completed, with significant improvement in pain and neurological function. At six months of follow-up, the patient showed an increase in her mJOA score, indicating improved functionality. This case demonstrates that the endoscopic technique can be effective and safe in treating cervical stenosis with spinal cord compression and myelopathy. However, further studies are needed to confirm its efficacy compared to other surgical approaches. Level of Evidence IV; Case Report.