Spine Surgery Publications

Featured Articles Written By Our Doctors

Dr. Kaixuan Liu

President of Atalntic Spine Center

As a global leader in minimally invasive spine surgery, Dr. Liu is constantly working to practice the most advanced and effective treatment options for orthopedic patients.

Below you can find some of his most recent published articles exploring advanced endoscopic and minimally invasive orthopedic treatment.

Learn More About Dr. Liu
Kaixuan Liu, MD, PhD. President of Atlantic Spine Center

Publications by Dr. Liu:

Select any article to read it in full or download it to review it later. Feel free to contact us if you have any questions regarding your treatment & learn your options.

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    A Series of Endoscopic Lumbar Foraminoplasty Treatment for Radiculopathy in an Obese and Physically Disabled Patient: Case Study

    Kai-Xuan Liu, MD, PhD

    Endoscopic lumbar foraminoplasty is a minimally invasive spine surgery that can be performed under local anesthesia in outpatient settings. The main purpose of the technique is to relieve the compressed foraminal nerve by enlarging the neural foramen. Under direct view provided by fluoroscopy and with the assistance of an endoscope, endoscopic spine surgeons can use the technique to free the nerve by removing compression caused by disc herniations, facet joint osteophytes, scar tissue, as well as excessive ligaments.

    Because of its minimally invasive nature and effectiveness in relieving symptoms associated with nerve compression, the technique has gained growing attention among endoscopic spine surgeons, as well as patients who need interventional pain management for their spinal conditions. In the past 2 decades, the technique has been modified to treat a wide range of spinal conditions, including disc herniation (1,2), foraminal stenosis (3-5), and degenerative spondylolisthesis (6). The technique has also been used to treat failed back surgery (5), as well as lumbar radiculopathy occurring after instrumented lumbar spinal fusion (7). Published results suggest that in carefully selected patient population, endoscopic lumbar foraminoplasty can achieve results comparable to traditional open surgery, but with significantly faster recovery and fewer complications.

    Despite the increasing number of publications on endoscopic lumbar foraminoplasty, reports on the usage of the technique in treating obese patients whose physical mobility has been impaired because of physical injuries, chronic pain, and failed surgery are limited.

    The purpose of this article is to present a case report of a male patient who was disabled because of back and leg pain caused by workplace injuries, and whose previous back surgeries not only had failed to effectively relieve the pain, but also distorted the anatomy of his spine. Limitations and potentials of endoscopic spine foraminoplasty in treating complex back pain syndromes will also be discussed.

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    Transforaminal Endoscopic Lumbar Procedure for Disc Herniations: A "Between” Technique

    Kai-Xuan Liu, MD, PhD and Bryan Massoud, M.D.

    Despite the advancement of surgical techniques in endoscopic spine surgeries, treatment of central and paracentral disc herniations, especially disc extrusions and disc sequestrations, remains challenging. On the basis of our experience with treating disc tears, disc herniations, and other spinal diseases, we have developed a new technique we call the "between" technique. This technique involves positioning the opening of the endoscope access cannula at the edge of the targeted disc with half of the opening being positioned inside the disc and the other half positioned in the epidural space. The "between" technique uses a blunt-ended dilator as a navigating tool in the epidural space to find the ideal access path and initial location for the access cannula. The technique is safe, effective, and easy to use. It has been proven particularly efficacious for the treatment of central and paracentral extruded disc herniations and sequestered disc herniations. The purpose of this Chapter is to describe this technique and introduce its application in removing central and paracentral disc extrusions and sequestrations.

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    Endoscopic Anterior Cervical Discectomy under Epidurogram Guidance

    Kai-Xuan Liu, MD, PhD and Bryan Massoud, M.D.

    Cervical discectomy is commonly required for spinal cord and nerve compression disorders. Currently, anterior cervical discectomy and fusion is the standard procedure for the treatment of cervical disc herniations and cervical degenerative disorders, whereas endoscopic cervical discectomy is considered an important alternative. Despite the advancement in surgical technology, endoscopically removing hard pathological tissues remains challenging. Inspired by lumbar epidurogram-guided decompression, we have developed an epidurogram-guided endoscopic cervical decompression technique. The technique uses contrast dye through cervical discography to generate an epidurogram. Under fluoroscopic view, the spinal cord is posterior to the contrast line. The endoscopic instruments can safely reach the epidural space, if it's necessary, as long as they stay anterior to the contrast line. We have used this technique to treat both soft and hard cervical disc herniations, and we have found it makes the surgical procedures safer when more aggressive decompression is required.

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    A Simple Technique of Accessing the L5-S1 Disc Space for Transforaminal Endoscopic Spine Surgery

    Hong-Fei Nie, MD, Jian-Cheng Zeng, MD, PhD, Kai-Xuan Liu, MD., PhD

    Transforaminal endoscopic spine surgery is increasingly used to treat a range of spinal conditions. The success of the surgery requires an accurate insertion of the guide needle and a precise placement of the working cannula and endoscope. However, such a precise placement is challenging for many surgeons to achieve when the pathology is located at the L5-S1 level. On the basis of our years of experience with performing transforaminal endoscopic spine surgery, we have developed a simple technique to help surgeons safely access the L5-S1 level. The technique has been proven intuitive and easy for experienced as well as inexperienced surgeons to learn. The key steps of the technique involve identifying an appropriate entry point on the skin and choosing an accurate trajectory angle for insertion. The purpose of this chapter is to report how to easily identify the entry point and choose a trajectory angle depending on the patient's anatomic characteristics.

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    Endoscopic Transforaminal Thoracic Foraminotomy and Discectomy for the Treatment of Thoracic Disc Herniation

    Hong-Fei Nie, MD and Kai-Xuan Liu, MD, PhD

    Thoracic disc herniation is a relatively rare yet challenging-to-diagnose condition. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Previously reported surgical approaches are often associated with high complication rates. Here we describe our minimally invasive technique of removing thoracic disc herniation, and report the primary results of a series of cases. Between January 2009 and March 2012, 13 patients with symptomatic thoracic disc herniation were treated with endoscopic thoracic foraminotomy and discectomy under local anesthesia. A bone shaver was used to undercut the facet and rib head for foraminotomy. Discectomy was achieved by using grasper, radiofrequency, and the Holmium-YAG laser. We analyzed the clinical outcomes of the patients using the visual analogue scale (VAS), MacNab classification, and Oswestry disability index (ODI). At the final follow up (mean: 17 months; range: 6–41 months), patient self-reported satisfactory rate was 76.9%. The mean VAS for mid back pain was improved from 9.1 to 4.2, and the mean ODI was improved from 61.0 to 43.8. One complication of postoperative spinal headache occurred during the surgery and the patient was successfully treated with epidural blood patch. No other complications were observed or reported during and after the surgery.

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    Techniques and Applications of Endoscopic Spine Surgery. Part I: Overview of Current Techniques

    Kai-Xuan Liu, MD, PhD

    Chronic pain is a serious health problem. Among chronic pain disorders, spinal pain caused by herniated discs and degenerative spinal diseases constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported ranging from 54% to 80%.

    Treatment of spinal pain generally starts with conservative options, including exercise, antipain and antiinflammation medications, physical therapy, chiropractic care and traction, acupuncture, and steroid injections. Many patients experience pain relief after receiving these treatments. But because conservative treatments target the symptoms, not the source of the pain, the pain relief resulted from conservative treatments is often temporal.

    If conservative treatments fail to produce satisfactory pain relief, surgery may be considered. Open spine surgical procedures are conventional surgical options for treating patients with spinal pain that does not respond well to conservative treatments. However, open techniques are often associated with tissue damage, relatively high complication rates, and long recovery. The drawbacks of open techniques compelled surgeons to search for less invasive surgical alternatives. The advances in visualization technology, surgical tools and instruments, and surgical techniques eventually made minimally invasive endoscopic spine surgery a reality.

    The objective of the first part of this 2-part review article is to overview the most commonly used techniques of endoscopic spine surgery. In the second part of the article, we’ll summarize the applications of these techniques in treating various spinal conditions, and evaluate the clinical evidence of the safety and effectiveness of these techniques in treating some of the major spinal conditions. Endoscopic spine techniques also play important roles in diagnosing spinal diseases and visualizing pain resources, but because of word limitation, this review article focuses on only the role of endoscopic spine techniques as a surgical treatment option.

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    Techniques and Applications of Endoscopic Spine Surgery. Part II: Safety and Effectiveness of Endoscopic Spine Surgery in Treating Spinal Conditions

    Kai-Xuan Liu, MD, PhD

    Chronic pain is a serious health problem. Treatment of spinal pain generally starts with conservative options. But if conservative treatments fail to produce satisfactory pain relief, surgery may be considered. Because of its many advantages, endoscopic spine surgery has spurred tremendous interest in recent years. The main goal of the new endoscopic spine surgical techniques is to achieve at least comparable clinical outcomes to conventional surgical options while reducing the operation-related tissue damage and high morbidity rates. In the past 10 to 15 years, many authors have reported their experience with endoscopic spine surgery for treating spinal conditions.

    A number of retrospective and prospective studies have attempted to evaluate the feasibility and safety of different endoscopic techniques, and a few randomized controlled clinical studies have compared the clinical outcomes of endoscopic techniques with conventional open spine surgery techniques in treating some common spinal conditions.

    The objectives of this second part of our 2-part review article are to 1) summarize the applications of these techniques in treating various spinal conditions, and 2) evaluate the clinical evidence of the safety and effectiveness of these techniques in treating some of the major spinal conditions. Endoscopic spine techniques also play important roles in diagnosing spinal diseases and visualizing pain resources, but because of word limitation, this review article focuses on only the role of endoscopic spine techniques as a surgical treatment option.

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