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This video presents a case of L4–5 unstable spondylolisthesis treated with full-endoscopic transforaminal lumbar interbody fusion (Endo-TLIF), emphasizing the GUARD (Glider Used as a Rotary Device) technique for nerve root protection. This innovative approach involves controlled rotation of the cage glider before cage insertion to minimize the risk of nerve root injury, a significant complication in Endo-TLIF procedures. The GUARD technique, validated in previous cadaveric studies, provides enhanced safety during cage insertion by protecting the nerve root. A 48-year-old woman with a 3-year history of progressive low back pain and bilateral lower extremity radiculopathy (right-sided predominance) was diagnosed with L4–5 unstable spondylolisthesis and spinal stenosis. After failure of conservative management, she underwent uniportal full-endoscopic facet-resecting transforaminal lumbar interbody fusion using the GUARD technique. Postoperatively, the patient experienced significant symptomatic improvement and resolution of radiculopathy, without any intraoperative nerve root injury or postoperative neurological deficits. This case demonstrates the effectiveness of the GUARD technique in reducing neurological complications and improving patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: Uniportal full-endoscopic transforaminal lumbar interbody fusion (FE-TLIF) carries a unique risk of nerve traction and abrasion injury during cage insertion. This study aims to evaluate the clinical efficacy of the GUARD technique and delayed ligamentum flavectomy in reducing postoperative radicular pain and neurapraxia in patients undergoing uniportal FE-TLIF. Methods: A retrospective analysis was conducted on 45 patients with an average age of 53.9±12.4 years who underwent either FE facet-sparing TLIF (FE fs-TLIF) or FE facet-resecting TLIF (FE fr-TLIF). Patients were divided into 2 groups: the sentinel group (21 patients) using traditional sentinel pin techniques, and the GUARD group (24 patients) using the GUARD technique with delayed ligamentum flavectomy. Patient-reported outcomes included the visual analogue scale (VAS) for leg and back pain, and Oswestry Disability Index. Complication rates, including incidental durotomy, postoperative neurapraxia, and hematoma, were also documented. Results: Postoperative radicular pain in the legs was significantly reduced at 6 weeks in the GUARD group compared to the sentinel group (VAS: 2.201 vs. 3.267, p=0.021). The incidence of postoperative neurapraxia was markedly lower in the GUARD group (0% vs. 19%, p=0.047). Both groups showed similar improvements in disc height, segmental lordosis, and lumbar lordosis at the 1-year follow-up, with no significant differences in endplate injury or fusion rates. Conclusion: The GUARD technique and delayed ligamentum flavectomy significantly enhance patient safety by reducing postoperative radicular pain and neurapraxia without incurring additional costs. These techniques are easy to learn and integrate into existing surgical workflows, offering a valuable improvement for surgeons performing FE-TLIF procedures. [ABSTRACT FROM AUTHOR]

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Study Design: The study included 2 fresh-frozen cadavers., Objective: To elucidate the positional relationship between surgical instruments and nerve roots during full endoscopic facet-sparing (FE fs-TLIF) and full endoscopic facet-resecting (FE fr-TLIF) transforaminal lumbar interbody fusion and propose safe instrumentation insertion procedures and recommend cage glider designs aimed at protecting nerve roots., Background: Endoscopic surgical techniques are increasingly used for minimally invasive lumbar fusion surgery, with FE fr-TLIF and FE fs-TLIF being common approaches. However, the risk of nerve root injury remains a significant concern during these procedures., Patients and Methods: Eight experienced endoscopic spine surgeons performed uniportal FE fr-TLIF and FE fs-TLIF on cadaveric lumbar spines, totaling 16 surgeries. Postoperation, soft tissues were removed to assess the positional relationship between the cage entry point and nerve roots. Distances between the cage entry point, traversing nerve root, and exiting nerve root were measured. Safe instrumentation design and insertion procedures were determined., Results: In FE fr-TLIF, the mean distance between the cage entry point and traversing nerve root was significantly shorter compared with FE fs-TLIF (3.30 ± 1.35 vs . 8.58 ± 2.47 mm, respectively; P < 0.0001). Conversely, the mean distance between the cage entry point and the exiting nerve root was significantly shorter in FE fs-TLIF compared with FE fr-TLIF (3.73 ± 1.97 vs . 6.90 ± 1.36 mm, respectively; P < 0.0001). For FE fr-TLIF, prioritizing the protection of the traversing root using a 2-bevel tip cage glider was crucial. In contrast, for FE fs-TLIF, a single-bevel tip cage glider placed in the caudal location was recommended., Conclusion: This study elucidates the anatomic relationship between cage entry points and nerve roots in uniportal endoscopic lumbar fusion surgery. Protection strategies should prioritize the traversing root in FE fr-TLIF and the exiting root in FE fs-TLIF, with corresponding variations in surgical techniques., Level of Evidence: Level V., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The objective of this study was to describe the surgical technique using an innovative nail-stem construct in treatment of periprosthetic humeral fractures with recalcitrant nonunion after total elbow arthroplasty (TEA)., Materials and Methods: Patients diagnosed with humeral recalcitrant nonunion in periprosthetic fractures and stem loosening after TEA were retrospectively recruited between 2018 and 2019. The demographic data and related clinical outcomes were recorded. We use a cutting length of the nail pushing into the humeral canal and then pull back distally to dock the tip of the humeral stem. The cement was packed into the humeral canal, and the periprosthetic bone defect was impacting with harvested allograft chip., Results: Patient age, gender, lesion site, number of previous surgeries, and the time period from the primary TEA to the nail-stem reconstruction were allocated. Moreover, the range of motion, degree of elbow stability, and level of pain were evaluated for each patient following this procedure. All the four patients achieved an optimal range of motion and secure stability with painless elbow at final follow-up., Conclusion: Our proposed nail-stem construct with double allogenous bone plate is a feasible alternative for revisional TEA in patients with implant loosening, periprosthetic humeral fractures, and recalcitrant nonunion., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Tzu Chi Medical Journal.)