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1. Annual Progress Report

2. Project title
“A study of clinical and radiological predictors
of ease of surgery in Interlaminar Endoscopy”

3. Principal Investigator (PI):
Dr VV Ramesh Chandra, Professor & HOD, Department of
Neurosurgery, SVIMS, Tirupati

4. Co-Principal Investigator
• Dr BCM Prasad, Senior Professor, Department of Neurosurgery,
SVIMS, Tirupati

5. Methodology
INCLUSION CRITERIA:
1.Patient age between 20-60 years.
2. Symptomatic lumbar radiculopathy, dysesthesias, or decreased motor
function.
3. Patient with persistent symptoms for at least 6 weeks, which is not
relieved by conservative therapy.
4. Patients with single level lumbar disc prolapse at L4-5 and L5-S1
levels.
5. Lumbar magnetic resonance imaging (MRI) showing central,
foraminal, lateral recess or extra-foraminal stenosis.

6. EXCLUSION CRITERIA:-
• Patients with multiple level disc prolapse.
• Patients with disc disease and instability
• Patients with calcified discs, severe stenosis, cauda equina syndrome,
painless weakness, or severe fibrotic tissue adhesions
• Patients with metastasis and spondylodiscitis.
• Patients who are medically unfit for surgery.
• Previous surgery at proposed treatment level.
• Patients not consenting for surgery.
• Disc prolapse or canal stenosis at L1-3 levels

7. • Data will be being collected prospectively from patients with Lumbar
Prolapsed intervertebral disc and lumbar canal stenosis treated by
endoscopic inter-laminar approach in the Department of Neurosurgery,
SVIMS, Tirupati , Andhra Pradesh, India. Patients are included in the
study after taking written Informed consent.
• All the patients with single level lumbar disc with or without canal
stenosis will be examined in detail and the clinical findings, visual
analogue scale score (VAS) for low backache and leg pain; Oswestry
Disability Index (ODI) will be assessed preoperatively and
postoperatively day 1, 3, and at 1 month, 3 months and 6 months
follow-up. Time taken to return to their regular activities will also be
assessed in their follow-up.

8. • All the patients will be subjected to radiological investigations which
include X-rays (SIEMENS, 500mA, India 2009) lateral views (flexion,
extension) and anteroposterior views , Magnetic resonance imaging- (MRI-
SIEMENS, 1.5TESLA, Germany 2002) to know the presence of disc
prolapse, type of disc, thecal sac compression/root compression and type of
spinal canal stenosis.
• Location of disc will be classified as Central, subarticular, foraminal and
extraforaminal. Grading of spinal canal stenosis will be done as Type I—
central canal stenosis (less than 100 mm2 cross-sectional area), Type II—
lateral recess stenosis, Type III—foraminal stenosis, and Type IV—
extraforaminal stenosis. MRI will be done preoperatively and immediate
postoperative period to look of amount of disc and spinal stenosis clearance

9. Date of start
• 1st June 2015

10. Duration
• 8 years

11. Objectives of the proposal
• To analyse factors responsible for technical difficulties while
performing percutaneous endoscopic interlaminar surgery.
• To analyse Clinico-radiological outcomes of patients who are
undergoing interlaminar endoscopic spine surgery in terms of Visual
analogue score (VAS), Oswestry Disability Index (ODI) score,
duration of surgery, and blood loss.
• To study complications among patients undergoing endoscopic
interlaminar approach and their prevention

12. Interim modification of objectives /methodology
• None

13. Detail progress of the work carried out during the
period
Study Duration: 8 years.
Accomplishments:
• Enrolled 88 patients, meeting the target sample size within the study
timeline.
• Conducted comprehensive clinical evaluations and radiological
assessments for all enrolled patients clinical findings, visual analogue
scale score (VAS) for low backache and leg pain; Oswestry Disability
Index (ODI) are assessed preoperatively
• Identified suitable candidates and performed interlaminar endoscopic
discectomy or decompression.
• Oswestry Disability Index (ODI), VAS, Time taken to return to daily
activities are assessed preoperatively and postoperatively day 1, 3, and at
1 month, 3 months and 6 months follow-up.

14. • Current Status: The study has progressed as planned, achieving
significant milestones in patient recruitment and evaluation.
Identified suitable candidates and performed interlaminar endoscopic
discectomy or decompression in 88 patients.
• The project has made substantial progress, meeting key milestones in
patient enrolment and evaluation. The study is well-positioned to
assess clinical and radiological predictors of ease of surgery in
Interlaminar Endoscopy

15. Results
Demographics
AGE GROUP PATIENTS PERCENTAGE
20-30 8 9.1%
31-40 24 27.3%
41-50 36 40.9%
51-60 20 22.7%
TOTAL 88 100%

16. Results
VAS ODI
0
1
2
3
4
5
6
7
8
9
10
Preop VAS
Post Op VAS
0
10
20
30
40
50
60
70
80
90
Preop ODI Post Op ODI

17. WORKING IMAGES OF EQUIPMENT IN USE

18. Summary sheet
Introduction:
• Interlaminar endoscopic spine surgery (IESS) has evolved as a solution to
overcome the difficulties of endoscopic transforaminal approach at lower
lumbar levels. But the advent of IESS has expanded the indications of
endoscopic surgery from discectomy at L5-S1 mainly and few L4-5 levels
to unilateral laminotomy with bilateral decompression for the management
of spinal stenosis.
• Not all patients are suitable candidates for IESS because of the anatomical
variations and degree of pathologies. Analyzing those clinical and
radiological factors which hinder the usage of IESS helps in better patient
selection, reducing the rate of complications and re-explorations for residual
pathologies.

19. Objectives:
• To analyse factors responsible for technical difficulties for IESS.
• To analyse clinico-radiological outcomes of patients who are
undergoing interlaminar endoscopic spine surgery in terms of Visual
analogue score (VAS), Oswestry Disability Index (ODI) score,
duration of surgery, and blood loss.
• To study complications among patients undergoing endoscopic
interlaminar approach and their prevention

20. Methodology:
• Patient Enrollment: Inclusion criteria based on low back pain characteristics
and inclusion criteria.
• Pain Assessment: Quantification of pain severity using the VAS, Disability
by ODI.
• Clinical Evaluation: Detailed medical history and physical examination.
• Radiological Investigations: MRI/CT scans and dynamic X-rays of the
lumbosacral spine.
• Imaging Findings Analysis: Expert radiologist assessment of joint
abnormalities.
• Exclusion of Surgical Conditions: Ensure study relevance by exclusion
criteria.
• Fitness Assessment: Routine investigations to determine patient suitability.
• Interlaminar endoscopic discectomy/decompression: Minimally invasive
procedure targeting disc/stenosis.
• Follow-up and Data Collection: Periodic assessments of pain levels and
patient-reported outcomes.

21. Results
• The mean age was 41.26 + 9.63 years.
• Mean operative time was 125 ± 38.41 minutes.
• Patients were ambulatory by 2.12 ± 0.83 days after surgery.
• Patients were hospitalized for 5.01 ± 1.34 days.
• Patients responded well to the surgery and showed a significant decrease in both VAS (7.27 + 1.13 vs
3.38 + 0.83, p<0.001) and ODI scores (59.34 + 10.86 vs 24.20 + 4.31, p<0.001) at their 6 months
follow‐up (p<0.001).
• Conversion from endoscopic to open procedure done for 3 cases (3.4%).
• Recurrance rate was found to 4.04% (4.5) in operated cases.
• Complications like dural injury occurred in 2 patients (2.27%)

22. RESULTS- PREDICTORS OF POOR OUTCOMES
• Disc residual – noted in 6 patients on radiology, only 1 patient has
been symptomatic and underwent open discectomy. Rest patients
have 3 in central, 1 upmigrated and 1 pre radicular type.
• Disc reccurence – noted in 2 cases on follow up at 4 months, and
other at 6 months. But better on medical management only.

23. RESULTS- PREDICTORS OF POOR OUTCOMES
1. Narrow interlaminar window
2. Medialised facets/facetal hypertrophy
3. Ligamentum flavum thickening
4. Severe lateral recess stenosis
5. Duration of symptoms >7 months.
6. Large central disc herniation.
7. Severe canal stenosis
8. Up/down migrated disk
9. Calcified disk
10. Osteophytes.

24. Research work which remains to be done under
the project
Upcoming Steps:
• Follow up assessment of post operative patients for interlaminar
endoscopy at 1, 3 and 6 month follow up.
• Further Analysis of collected data to assess the clinical and
radiological predictors and complications of interlaminar endoscopy
to complete the project for patients who are in follow up.
• Publication of the project once the follow up period is completed.

25. Applied value of the project
• The study's outcomes hold potential for analysing and
improving the clinical, radiological predictors of outcome and
complications in interlaminar endoscopy with implications for
enhancing patient quality of life.

26. Any publications
• To be sent
• Presented paper on- “Analysis of factors for ease of surgery in
Interlaminar Endoscopic Lumbar Discectomy“ at APNEUROCON
2022 on 3rd – 4th September at Tirupati.

27. Any patents applied for
• None

28. If additional budget or staff is required for the
remaining part of the research work
• None