Indirect spinal canal decompression in burst fractures treated with pedicle screw instrumentation

STUDY DESIGN: Prospective evaluation of spinal canal areas in 67 consecutive burst fractures between T12 and L2 treated by reduction and stabilization with a pedicle fixator. OBJECTIVES: Assessment of the efficacy of "indirect" spinal canal decompression in a large series of burst fractures. SUMMARY OF BACKGROUND DATA: Up to 50% of burst fractures cause neurologic impairment. Reduction and posterior instrumentation is the most common surgical treatment. This also reduces spinal canal encroachment by indirect decompression. No consensus exists as to the consistency and adequacy of such indirect decompression. METHODS: Spinal canal areas were measured on preoperative and postoperative computed tomography scans. The degree of encroachment was compared with clinical and radiographic variables for possible correlation. RESULTS: Spinal canal encroachment was more severe among patients with neurologic deficits than among the neurologically intact. Postoperatively, mean encroachment was reduced from 35% to 12% at T12, from 37% to 17% at L1, and from 52% to 35% at L2. Loss (and postoperative restoration) of anterior vertebral height correlated best with the degree of canal encroachment (and its reduction), especially in Denis Type A burst fractures. In Denis Type B fractures, canal compromise usually was less severe and fragment reduction better in patients older than 40 years of age than in younger patients. CONCLUSIONS: Indirect decompression in burst fractures averages about half of the preexisting encroachment. Results are usually better at T12 and L1 than at L2. Additional or secondary decompression is rarely indicated if these fractures are treated early and by experienced surgeons. Burst Type B fractures in patients older versus younger than 40 years of age differ in many respects.     

Functional morphology of the spinal canal after endplate, wedge, and burst fractures

The plasma-ion shower method is an effective technique for the SEM examination of un-coated electrically non-conductive specimens. However, milling damage to specimens cannot be prevented by the irradiation method using accelerated Ar ion beam. We, therefore, applied positive ions obtained by plasma discharge to the specimen like a shower by reflecting from the target electrode surface. He, N2 or Ar was used as the environmental gas, and the discharge voltage was varied from 200 V to 1000 V. At 5 kV to 25 kV of SEM accelerating voltage, it was possible to visualize un-coated hard and soft biological and inorganic specimens under 5 mA or 10 mA of discharge current and 5 min or 10 min of processing time.     

Thoracolumbar burst fractures. The clinical efficacy and outcome of nonoperative management

There continues to be considerable controversy regarding the management of thoracolumbar burst fractures. Most feel that failure of the middle osteoligamentous complex, particularly with retropulsion of fragments into the spinal canal, is an indication for operative management. Others advocate postural reduction and prolonged bedrest for such injuries. The purpose of this study was to 1) review the clinical outcome and efficacy of closed management of thoracolumbar burst fractures; and 2) quantify what, if any, remodeling occurs in the bony canal as measured by serial CT. Forty-one patients who presented with a burst fracture of the thoracolumbar spine without neurologic deficit were reviewed clinically and radiographically following nonoperative management. At injury, canal compromise averaged 37% (range, 16-66%); 26 patients had at least 30% canal compromise. During treatment, one patient developed neurologic deterioration that prompted surgery; all other patients remained neurologically intact. At average follow-up of 2 years, an overall outcome evaluation indicated that 49% of the patients had excellent outcomes relative to pain and function; 17%, good; 22%, fair; and 12%, poor. Approximately 90% of the patients had a satisfactory work status relative to factors associated with their burst fracture. Serial roentgenograms documented significant progression in body collapse, which averaged 8% (P < 0.0001) from injury to follow-up. On the other hand, serial CTs documented significant improvement from injury to follow-up for canal compromise and midsagittal diameter. Average improvements in canal compromise and midsagittal diameter were 22% (P < 0.0001) and 11% (P < 0.0001), respectively. Only three patients had canal compromise greater than 30%, no patients had canal compromise greater than 40%, and no patients experienced canal area deterioration over time. On average, nearly two-thirds of the fragment occluding the canal resorbed, with most remodeling complete within one year. For patients with burst fractures presenting neurologically intact, we obtained the following findings: 1) nonoperative management yields acceptable results; 2) following nonoperative management, bony deformity (i.e., kyphosis and body collapse) progresses marginally relative to the rate of canal area remodeling; 3) incidence of subsequent neurologic deficits is quite low; and 4) initial radiographic severity of injury or residual deformity following closed management does not correlate with symptoms at follow-up. This pattern of results suggests nonoperative management as the preferred treatment in these circumstances.     

Microdecompression and uninstrumented single-level fusion for spinal canal stenosis with degenerative spondylolisthesis

STUDY DESIGN: A retrospective review was completed on 21 patients who had a "least invasive" (one or two level) microdecompression and uninstrumented single-segment lumbar fusion for spinal canal stenosis with degenerative spondylolisthesis. OBJECTIVE: To determine whether a "least invasive" approach to lumbar spinal canal stenosis and degenerative spondylolisthesis would yield acceptable results. SUMMARY OF BACKGROUND DATA: The prevailing surgical technique for symptomatic spinal canal stenosis with degenerative spondylolisthesis is a wide midline decompression and instrumented fusion. METHODS: On an average of 38 months postoperatively, 21 patients were personally assessed on four scores: 1) their overall satisfaction with the outcome of surgery, 2) an analog back and leg pain scale, 3) a functional evaluation scale, and 4) Ferguson (upshot) anterior-posterior lumbosacral and lateral flexion-extension radiographs. RESULTS: The overall satisfactory outcome on all four scales was 16 (76%) of 21. Twenty of twenty-one patients had relief of their claudicant leg pain; the overall fusion rate was 18 (86%) of 21. Two of three patients with a pseudarthrosis had a successful outcome on the patient-oriented outcome (1, 2, and 3) scales (excluding the radiograph scale), and one was a failure. One patient with a solid fusion was a failure because of continuing back pain. One patient with a solid fusion was a failure because of continuing leg pain. The overall satisfactory outcome on the nonradiographic scales was 18 of 21, for an 86% patient satisfaction rate. CONCLUSIONS: In this retrospective study, a "least invasive" surgical approach to lumbar degenerative spondylolisthesis with spinal canal stenosis causing claudicant leg pain produced acceptable results.     

Associations between spinal deformity and outcomes after decompression for spinal stenosis

STUDY DESIGN: Prospective observational study. OBJECTIVES: To examine associations between radiographic parameters (scoliosis and olisthesis) and outcomes of surgery for degenerative spinal stenosis. SUMMARY OF BACKGROUND DATA: Preoperative degenerative scoliosis generally is thought to be associated with an unfavorable outcome of surgery for spinal stenosis. Data on the relationship between an increase in olisthesis after laminectomy for spinal stenosis and outcomes of surgery are sparse and conflicting. METHODS: Radiographs were obtained before surgery and at least 6 months after surgery and coded for preoperative scoliosis and change in olisthesis after surgery. The reviewers of radiographs were blind to outcome information. Patients completed questionnaires on demographic and clinical data as well as on back pain, lower extremity pain, walking capacity, and satisfaction with surgery. Associations between radiographic data and patient reported outcomes were examined with the Spearman rank correlation and confirmed with multiple linear regression models that adjusted for potential confounders. RESULTS: Ninety patients met eligibility criteria. Preoperative scoliosis was associated with less improvement in back pain at 6 months and at 24 months after surgery. An increase in olisthesis after surgery was associated with greater improvement in lower extremity pain at 6 months and at 24 months after surgery. An increase in olisthesis also was associated with greater improvement in walking capacity at 6 months and at 24 months after surgery. In multivariable analyses that adjusted for potential confounders, a change in olisthesis was not associated significantly with greater improvement in any of the outcomes. CONCLUSION: The data support the widely held view that preoperative scoliosis is associated with an unfavorable outcome after decompression for degenerative lumbar spinal stenosis. Increase in olisthesis was not associated with unfavorable results. In fact, there was a weak trend toward better outcomes with greater slip. These data indicate that minor increases in olisthesis after surgery for spinal stenosis generally are tolerated well.     

Two-level burst fractures: clinical evaluation and treatment options

We have studied the resistance of Toxoplasma gondii-infected mice to subsequent infection with Cryptococcus neoformans. Mice infected with the moderately virulent ME49 strain of T. gondii are resistant to proliferation of yeast cells in their brains after intravenous inoculation of the serotype A C. neoformans strain 184. The resistance serves to limit proliferation of yeast cells that colonize the brain. Maximal levels of resistance correlate not with maximal systemic specific anti-Toxoplasma resistance but rather with high levels of inflammatory response, presumably to parasites released from cysts in the brain. Resistance is localized, as mice infected with ME49 show only limited resistance in their lungs after intratracheal instillation of yeast cells, but there is substantial protection against development of cerebral cryptococcosis.     

Thoracic spinal stenosis: diagnostic and treatment challenges

Thoracic stenosis may be defined by a narrowing of the anteroposterior (AP) diameter of the thoracic spinal canal to < 10 mm. Primary thoracic stenosis, documented when myelography is carried beyond the thoracolumbar junction into the upper thoracic canal, is most frequently associated with lumbar stenosis, whereas secondary stenosis, attributed to endocrinopathies and systemic diseases, more typically involves the entire spinal canal. Recognition of the presence of primary or secondary thoracic stenosis and the entire extent of attendant disease in the adjacent cervical or lumbar regions is essential to proper surgical management. Nine cases of primary and one instance of secondary thoracic spinal stenosis were reviewed. Seven of nine patients with primary thoracic stenosis had accompanying lumbar involvement, whereas one patient with secondary stenosis attributed to acromegaly had cervical, thoracic, and lumbar stenosis.     

Adenoid cystic carcinoma of the external auditory canal: correlation between histological features and MRI appearances

A rare case of adenoid cystic carcinoma of the external auditory canal with magnetic resonance imaging appearances is reported. Both T1 weighted and T2 weighted MR images showed the tumour as a hypointense mass, although there was marked contrast enhancement. Microscopic examination of the resected tumour showed a preponderance of solid tumour cell nests. According to previous reports, these pathological and radiological findings indicate a poor prognosis.     

Clinical analysis of two-level compression of the cauda equina and the nerve roots in lumbar spinal canal stenosis

STUDY DESIGN: This study is a prospective, clinical study assessing the efficacy of selective decompression of the responsible level in two-level stenosis in accordance with neurologic findings defined by the gait load test, and functional diagnosis based on selective nerve root block. OBJECTIVE: To clarify the clinical features of two-level stenosis regarding the neurologic level responsible for the symptoms, neurogenic intermittent claudication, and the outcome of selective decompression. SUMMARY OF BACKGROUND DATA: Experimental studies have indicated that double-level compression of the cauda equina induces a more severe impairment of nerve function than does single-level compression. However, few studies have focused on the clinical importance of two-level stenosis. The clinical effects of two-level stenosis on the cauda equina and nerve roots are unknown. METHODS: A total of 81 patients with lumbar spinal canal stenosis due to spondylosis and degenerative spondylolisthesis were divided into two groups, two-level stenosis at L3-L4 and L4-L5, and one-level stenosis at L4-L5, based on myelography. The types of neurogenic intermittent claudication, the level responsible for neurologic findings, and the postsurgical outcome were compared between both groups. The level responsible for the symptoms in two-level stenosis was determined in accordance with neurologic findings on the gait load test and functional diagnosis based on a selective nerve root block. All patients underwent a prospective, selective decompression at the neurologically responsible level only. The average follow-up period was 4.6 years (range, 1-8 years). RESULTS: The patients with two-level stenosis more frequently had cauda equina symptoms than those with one-level stenosis, except patients with degenerative spondylolisthesis. It was therefore assumed that two-level stenosis was associated with cauda equina impairment, Changes in neurologic condition before and after the gait test were observed in four patients with two-level stenosis. Finally, for 28 patients with two-level stenosis, the levels responsible for the neurologic symptoms were the caudal level (L4-L5) in 22 patients, the cranial level (L3-L4) in 1 patient, and both cranial and caudal levels (L3-L4 and L4-L5) in 5 patients. All stenotic levels on the myelogram were not always symptomatic in two-level stenosis. However, in one-level stenosis, all of the responsible levels completely corresponded to the myelogram. Selective decompression only at the neurologically responsible level improved neurogenic intermittent claudication in all patients. The asymptomatic levels at which the stenotic condition was left unchanged at surgery did not become symptomatic at follow-up; in addition, there was no significant difference in the postoperative outcome between two-level stenosis and one-level stenosis. CONCLUSIONS: Two-level stenosis in patients with lumbar spondylosis is associated with production of cauda equina lesions. The gait load test provides information regarding changes in symptoms and neurologic condition during exercise. The responsible levels should be determined based on neurologic findings after the gait load test and a selective nerve root block. It is uncommon for both stenotic levels to be symptomatic in patients with two-level stenosis. Less invasive surgery such as selective decompression for the responsible level in patients with two-level stenosis is a useful technique with a good potential for long-term success.     

An immunological correlation between the anchoring filaments of initial lymph vessels and the neighboring elastic fibers: a unified morphofunctional concept

More than 25 years have passed since immunoglobulin A (IgA) nephropathy was introduced as a disease entity independent of glomerulonephritis. It has been known that more than 30% of cases have gone into end-stage renal failure within 20 years, indicating the presence of a chronic active group in this disease. Histologically this disesase is composed of at least three types of tissue damage: (i) minimal inflammation including deposition of IgA-containing substances with minor matricial increase; (ii) acute lesions characterized by matricial damage of glomerular basement membrane (membranolysis) and/or mesangial matrix (mesangiolysis) with inflammatory cell accumulation and/or intrinsic cell proliferation; and (iii) chronic lesions mainly composed of postinflammatory sclerosis. The progression is actually accelerated by the frequency of acute lesions, resulting in increased glomerular sclerosis foci. In such a situation, the histologic grading and staging (G-S) system is proposed, with the aim of having a more precise understanding of the disease process. The histological grade (G) is estimated by the extent of acute glomerular and tubulointerstitial lesions, and the stage (S) is evaluated by the increase of extracellular matrices of the glomeruli and interstitial fibrosis. The evaluation of G and S is expressed semiquantitatively for more helpful clinical use.     

Ischemic stroke: relation of age, lesion location, and initial neurologic deficit to functional outcome

OBJECTIVE: Establish the relation between age, gender, initial neurologic deficit, stroke location, prior stroke, hemisphere of stroke, and functional outcome in ischemic stroke. DESIGN: Single group, multivariate, repeated measures design with 327 persons having ischemic stroke recruited from 20 participating centers. SETTING: Twenty European stroke centers. PATIENTS: Consecutive admissions of men and women between the ages of 40 and 85 yrs with a hemispheric stroke caused by middle cerebral artery ischemia and a Unified Neurological Stroke Scale score of 5 to 24. INTERVENTIONS: Inpatients enrolled in the trial received traditional rehabilitation therapies including physical therapy, occupational therapy, and speech therapy when appropriate. MAIN OUTCOME MEASURES: Barthel Index computed at 7 to 10 days and 3 months poststroke. RESULTS: Positive functional outcomes were significantly related to the absence of prior strokes, a younger age, a less severe initial neurologic deficit, stroke involving cortical structures, and dominant (left hemisphere) lesions. CONCLUSIONS: Despite some inconsistencies in existing literature, standardized prospective examination of outcome after stroke clearly demonstrated the effect of age, initial severity of stroke, and lesion location as predictors of functional outcome.     

On spinal noradrenaline receptor supersensitivity: correlation between nerve terminal densities and flexor reflexes various times after intracisternal 6-hydroxydopamine

The noradrenaline (NA)-dependent hindlimb flexor reflex that can be elicited by pinching the foot of acutely spinalized rats given nialamide-DOPA or clonidine was evaluated different time intervals (14 days-6 months) after intracisternal injections of 6-OH-dopamine (6-OH-DA) and correlated to the degree of bulbospinal catecholamine (CA) denervation as seen by Falck-Hillarp fluorescence histochemistry. Six and 14 days after 6-OH-DA, when almost all NA nerve terminals of the spinal cord had degenerated, the NA receptors where supersensitive to stimulation with clonidine as evidenced by an increased flexor reflex. This supersensitivity gradually disappeared as new nerve terminals were formed in the grey matter of the spinal cord during the following 3-6 months. The supersensitivity phenomenon 14 days after 6-OH-DA could also be demonstrated by L-DOPA given to animals pretreated with 100 mg/kg nialamide. Using this relatively low dose of nialamide, almost no reflex response was seen in the control group. Using a higher degree of monoaminoxidase inhibition (nialamide 200 mg/kg) also non-supersensitive, NA receptors became maximally stimulated. Therefore, 6-OH-DA treated rats now showed a weaker reflex than controls, the reflex response being directly correlated to the number of nerve terminals present that could form NA from the precursor. Using 5,6-dihydroxytryptamine, which selectively destroys 5-hydroxytryptamine (5-HT) nerves, it was shown that the flexor reflex changes were specifically related to the NA nerves and unchanged by the simultaneous presence or absence of 5-HT nerve terminals. This was further supported by the finding of a correlation between amount of nerve terminals and flexor reflex responses in individual animals, especially at longer survival times both in the clonidine and the nialamide-DOPA experiments.     

Dimensions of the lumbar spinal canal: variations and correlations with somatometric parameters using CT

The aim of this study was to investigate the correlation of vertebral dimensions with somatometric parameters in patients without clinical symptoms and radiological signs of central lumbar spinal stenosis. One hundred patients presenting with low back pain or sciatica were studied with CT. In each of the L3, L4 and L5 vertebra three slices were taken with the following measurements: 1. Slice through the intervertebral disc: (a) spinal canal area; (b) interarticular diameter; (c) interligamentous diameter. 2. Slice below the vertebral arcus: (a) dural sac area; (b) vertebral body area. 3. Pediculolaminar level: (a) anteroposterior diameter and interpedicular diameter of the spinal canal; (b) spinal canal area; (c) width of the lateral recesses. The Jones-Thomson index was also estimated. The results of the present study showed that there is a statistically significant correlation of height, weight and age with various vertebral indices. The conventional, widely accepted, anteroposterior diameter of 11.5 mm of the lumbar spinal canal is independent of somatometric parameters, and it is the only constant measurement for the estimation of lumbar spinal stenosis with a single value. The present study suggests that there are variations of the dimensions of the lumbar spinal canal and correlations with height, weight and age of the patient.     

Motor and somatosensory conduction time between the cortex and the Erb point in patients suffering from cervical spinal stenosis and tumour

Biochemical experiments by others have indicated that protein kinase C activity is present in the rod outer segment, with potential or demonstrated targets including rhodopsin, transducin, cGMP-phosphodiesterase (PDE), guanylate cyclase, and arrestin, all of which are components of the phototransduction cascade. In particular, PKC phosphorylations of rhodopsin and the inhibitory subunit of PDE (PDE ) have been studied in some detail, and suggested to have roles in downregulating the sensitivity of rod photoreceptors to light during illumination. We have examined this question under physiological conditions by recording from a single, dissociated salamander rod with a suction pipette while exposing its outer segment to the PKC activators phorbol-12-myristate,13-acetate (PMA) or phorbol-12,13-dibutyrate (PDBu), or to the PKC-inhibitor GF109203X. No significant effect of any of these agents on rod sensitivity was detected, whether in the absence or presence of a background light, or after a low bleach. These results suggest that PKC probably does not produce any acute downregulation of rod sensitivity as a mechanism of light adaptation, at least for isolated amphibian rods.     

Carotid stenosis: a comparison between MR and spiral CT angiography

To assess the impact of demographic and clinical factors on prognosis in patients with systemic lupus erythematosus (SLE), we studied a cohort composed of 566 patients in Huashan Hospital between 1959 and 1992 who were followed up to June 30, 1993. The survivorship was examined through life table analysis. The results showed that the survival rate from the time of SLE onset was 93% at 1 year, 73% at 5 years, and 60% at 10 years. On univariate analysis, we found that the following factors worsened the probability of survival: male, neuropsychiatric manifestations, pleurisy-pericarditis, hematological disorders, renal involvement, hypocomplementemia, abnormal electrocardiograph, and high corticosteroid dose of treatment. The time that the C3 depression occurred in the course of SLE affected the survival more significantly than did its decreased levels. The earlier the occurrence of C3 depression, the lower the patient's survival probability. On multivariate analysis, the independent risk factors were male gender, abnormal electrocardiograph, hypocomplementemia, and high corticosteroid dose of treatment. All of these indicated that clinical features of SLE might have value as predictors for its prognosis and that the occurrence of the decreased C3 in the early course of SLE might be the most important factor.     

Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements

The purpose of this review is to present current information from the literature regarding the pathoanatomy, clinical presentation, differential diagnosis, treatment, and outcome assessment methods for patients with lumbar spinal stenosis. Lumbar spinal stenosis is a frequently encountered condition, particularly in the elderly. Treatment requires an accurate diagnosis, but differential diagnosis of lumbar stenosis can be difficult. The literature to date has focused primarily on surgical treatment. The long-term efficacy of surgery has been questioned, and surgical procedures are associated with increased costs and risks of morbidity in an elderly population. A trial of conservative care is recommended in most cases, but there are presently no randomized controlled studies in the literature comparing surgical versus conservative management, or evaluating the effectiveness of any specific conservative treatment approach. The existing literature has further been criticized for having poorly defined outcome measures. The assessment of treatment outcomes should be multifactorial, including measures of pathoanatomy and impairments, as well as patient-centered measures such as level of disability, patient expectations, and satisfaction. The present level of understanding of lumbar spinal stenosis is deficient in many areas, including differential diagnosis, treatment, and outcome assessment. Future research should address these deficits to improve the management of patients with this condition.     

Health behavior in persons with spinal cord injury: development and initial validation of an outcome measure

OBJECTIVE: To describe the development and initial psychometric properties of a new outcome measure for health behaviors that delay or prevent secondary impairments associated with spinal cord injury (SCI). DESIGN: Persons with SCI were surveyed during routine annual physical evaluations. SETTING: Veterans Affairs Medical Center Spinal Cord Injury Unit, which specializes in primary care for persons with SCI. PARTICIPANTS: Forty-nine persons with SCI, aged 19-73 years, 1-50 years post-SCI. MAIN OUTCOME MEASURE: The newly developed Spinal Cord Injury Lifestyle Scale (SCILS). RESULTS: Internal consistency is high (alpha = 0.81). Correlations between clinicians' ratings of participants' health behavior and the new SCILS provide preliminary support for construct validity. CONCLUSIONS: The SCILS is a brief, self-report measure of health-related behavior in persons with SCI. It is a promising new outcome measure to evaluate the effectiveness of clinical and educational efforts for health maintenance and prevention of secondary impairments associated with SCI.     

Spontaneous burst fracture of the thoracolumbar spine in osteoporosis associated with neurological impairment: a report of seven cases and review of the literature

This is a report of seven patients suffering from osteoporosis, who sustained unstable burst fractures in the thoracolumbar spine associated with neurological impairment, without trauma. The manner of presentation, the neurological involvement, the radiological findings, as well as the surgical treatment with respect to functional and neurological recovery are discussed.     

Virtual bronchoscopy: the correlation between endoscopic simulation and bronchoscopic findings

PURPOSE: We carried out a preliminary clinical validation of 3D spiral CT virtual endoscopic reconstructions of the tracheobronchial tree, by comparing virtual bronchoscopic images with actual endoscopic findings. MATERIALS AND METHODS: Twenty-two patients with tracheobronchial disease suspected at preliminary clinical, cytopathological and plain chest film findings were submitted to spiral CT of the chest and bronchoscopy. CT was repeated after endobronchial therapy in 2 cases. Virtual endoscopic shaded-surface-display views of the tracheobronchial tree were reconstructed from reformatted CT data with an Advantage Navigator software. Virtual bronchoscopic images were preliminarily evaluated with a semi-quantitative quality score (excellent/good/fair/poor). The depiction of consecutive airway branches was then considered. Virtual bronchoscopies were finally submitted to double-blind comparison with actual endoscopies. RESULTS: Virtual image quality was considered excellent in 8 cases, good in 14 and fair in 2. Virtual exploration was stopped at the lobar bronchi in one case only; the origin of segmental bronchi was depicted in 23 cases and that of some subsegmental branches in 2 cases. Agreement between actual and virtual bronchoscopic findings was good in all cases but 3 where it was nevertheless considered satisfactory. The yield of clinically useful information differed in 8/24 cases: virtual reconstructions provided more information than bronchoscopy in 5 cases and vice versa in 3. Virtual reconstructions are limited in that the procedure is long and difficult and needing a strictly standardized threshold value not to alter virtual findings. Moreover, the reconstructed surface lacks transparency, there is the partial volume effect and the branches < or = 4 pixels phi and/or meandering ones are difficult to explore. CONCLUSIONS: Our preliminary data are encouraging. Segmental bronchi were depicted in nearly all cases, except for the branches involved by disease. Obstructing lesions could be bypassed in some cases, making an indication for endoscopic laser therapy. Future didactic perspectives and applications to minimally invasive or virtual reality-assisted therapy seem promising, even though actual clinical applications require further studies.