Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for treating elderly patients with lumbar central canal stenosis

OBJECTIVE Surgical decompression via a posterior interlaminar approach is widely used for treating lumbar central canal stenosis (LCCS). However, this surgical approach poses a challenge for elderly patients with comorbidities. Thus, the authors tried a new surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia to treat such patients. The aim of this study was to evaluate the safety and effectiveness of surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for patients with LCCS. METHODS Patients with LCCS who underwent surgical decompression, performed by a single surgeon, between January 2016 and March 2019 were retrospectively analyzed. All patients received decompression via the unilateral intervertebral foraminal approach with local anesthesia. Visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, modified Macnab criteria, walking distance, and Schizas classification were used as outcome predictors. Additionally, a decompression evaluation method was designed for use after spinal endoscopic surgery. RESULTS Overall, 23 patients with a mean age of 69 years were included in this study, with a mean follow-up of 28 months. Low-back and leg pain were significantly improved after decompression surgery. Postoperative ODI scores and walking distances were statistically significantly better than before surgery. Postoperatively, the Schizas classification for all patients was improved by at least 1 grade compared with the preoperative grade. No complications occurred during the follow-up period. According to the novel decompression evaluation method, all patients had at least achieved decompression in part 123+B. CONCLUSIONS Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia showed promising outcomes in the treatment of elderly patients with LCCS. Additionally, a proposed postoperative decompression evaluation method can help guide surgical decompression.

Comparative Analysis of Non-Full and Full Endoscopic Spine Technique via Interlaminar Approach for the Treatment of Degenerative Lumbar Spinal Stenosis: A Retrospective, Single Institute, Propensity Score-Matched Study

Study Design: Retrospective study. Objective: To compare the clinical efficacy of posterior lumbar laminectomy decompression under full endoscopic technique (Endo-LOVE) and percutaneous endoscopic medial foraminal decompression (PE-MFD) in the treatment of degenerative lumbar spinal stenosis (DLSS). Methods: Between April 2017 and April 2018, 96 patients with DLSS underwent Endo-LOVE or PE-MFD, including 58 with Endo-LOVE and 38 with PE-MFD. After propensity score matching (PSM), patient characteristics, operation time, intraoperative fluoroscopy times, postoperative bedridden time, hospital stay and postoperative complications were recorded and compared. The clinical efficacy was evaluated according to Oswestry disability index (ODI), visual analogue scale (VAS), lumbar disease JOA and modified MacNab criteria. Results: A total of 96 patients with DLSS were included in the study. After PSM, the 2 groups were comparable in patient demographic and baseline characteristics. The operation time and intraoperative fluoroscopy times in PE-MFD group were significantly more than those in Endo-LOVE group ( P < .05). The operation time in PE-MFD group was significantly less than that in Endo-LOVE group ( P < .05). The intraoperative fluoroscopy times in PE-MFD group were significantly more than that in Endo-LOVE group ( P < .05). The ODI, VAS and lumbar disease JOA in the 2 groups were significantly improved comparing with those before operation ( P < .05). According to the modified MacNab criteria, the excellent and good rates of the 2 groups were 93.5% in Endo-LOVE group and 87.1% in PE-MFD group ( P > .05). Conclusion: Endo-LOVE and PE-MFD technique can both effectively treat DLSS, and the short-term follow-up results are positive. Endo-LOVE technique has the advantages of fast puncture positioning, less radiation exposure and wider indications. However, PE-MFD needs more radiation exposure and has the possibility of incomplete decompression for complex multiplanar spinal stenosis.

Ten-Step Minimally Invasive Treatment of Lumbar Giant Disc Herniation via Unilateral Tubular Laminotomy for Bilateral Decompression: 2-Dimensional Operative Video

Giant disc herniation (GDH) is generally defined as a lumbar disc herniation that obstructs 50% or more of the space in the spinal canal.1-3 Common treatment options for GDH include unilateral interlaminar approach, bilateral approach, or open full laminectomy.4,5 Surgical treatment of GDH may be challenging because severe bilateral compression of neural elements in the spinal canal increases the risk of iatrogenic injury to nerve roots and dura. The surgical approach can be further complicated by calcification, hardening, and dehydration of the GDH tissue. The prevailing opinion in the literature is that giant disc herniations cannot safely be treated via tubular minimally invasive approaches.5-7 In this video, we present a case of a 52-yr-old male patient with a history of progressive low back pain that radiates bilaterally from the buttocks toward the posterior legs and knees for 2 yr because of a GDH at the L4-5 level. The patient was treated via a tubular “over-the-top” minimally invasive decompression in order to first provide generous bilateral decompression of neural elements and dura.8,9 After sufficient decompression at the surgical level, the discectomy was performed via an ipsilateral piecemeal resection of the GDH. The “over-the-top” contralateral mobilization of disc herniation was also achieved with this approach, which facilitated the removal of the entire disc fragment. Patient consent was obtained prior to performing the procedure. Therefore, GDH should not be considered as a contraindication for tubular decompression when this modified technique is performed.

Comparative Study of the Percutaneous Endoscopic Interlaminar Approach and Transforaminal Approach in the Treatment of Calcified Lumbar Disc Herniation

Background: Percutaneous endoscopic lumbar discectomy (PELD) is a relatively safe and effective minimally invasive surgery in the treatment of calcified lumbar disc herniation (CLDH). However, studies on percutaneous endoscopic interlaminar discectomy (PEID) and percutaneous endoscopic transforaminal discectomy (PETD) for CLDH have rarely been reported. This research aimed to compare the clinical efficacy of PEID and PETD for L5-S1 CLDH.Methods: We retrospectively analyzed 42 consecutive patients with L5-S1 CLDH treated with PELD at our institution from August 2016 to December 2019. Patients were divided into PEID group (n = 24) and PETD (n = 18) group according to the surgical methods. The demographic characteristics and surgical results of the two groups were compared. Clinical outcomes were estimated by the visual analog scale (VAS) for leg pain, Oswestry disability index (ODI) and modified MacNab criteria.Results: All patients were successfully operated on by PEID or PETD. No significant differences in the demographic characteristics, intraoperative blood loss, postoperative hospital stay and complication rate were noted between the PEID and PETD groups (P > 0.05). The excellent and good rates in the PEID group were similar to those in the PETD group (91.67% vs 88.89%, P > 0.05), whereas the PEID group exhibited superior results for operative time (m) (64.58 ± 5.88 vs 85.56 ± 9.06, P < 0.05) and fluoroscopy times (n) (2.96 ± 0.96 vs 13.33 ± 2.64, P < 0.05) compared with the PETD group.Conclusions: PEID had achieved good clinical efficacy as PETD for L5-S1 CLDH. Compared with PETD, PEID had the advantages of shorter operative time and a reduced number of fluoroscopy times in the treatment of CLDH.

Neurological safety of spinal surgery for nucleus pulposus removal under spinal endoscopic imaging guided by inter laminar spine

Original Article Bin Chen1, Zengfeng Du2 ABSTRACTObjective: To explore the technical points, approach selection and short-term clinical efficacy of PELD through the intervertebral foramina or interlaminar approach in the treatment of highly shifted LDH. Methods: From September 2018 to June 2020, 19 patients with highly shifted LDH were treated with PELD in The First Hospital of Yulin. It included, 10 males and 9 females; aged 34 to 69 years, with an average of 48 years. Thirteen cases were shifted to the caudal side, and six cases were shifted to the head side. The responsible segments included L3/41 cases, L4/511 cases, and L5/S17 cases. All patients had symptoms of low back and leg pain. The Sowerby dysfunction index (ODI) was 63.5%±10.7% before surgery. The visual analogue scale of pain (VAS) was low back pain (5.2±2.1) and leg pain (7.1±2.4). 14 cases used transforaminal approach, and 5 cases used translaminar approach. Results: All cases completed the operation successfully, the operation time was 60~110min, with an average of 70 minutes. The follow-up time ranged from 6 to 42 months, with an average of 20.8 months. At the last follow-up, ODI was 10.8%±6.8%, VAS back pain score (2.1±1.1) and leg pain score (1.8±0.9). Compared with preoperative, ODI and VAS scores were significantly decreased (P<0.05). The results of Mac Nab method were 14 excellent, four good, and one fair. During the follow-up period, one patient’s leg pain symptoms recurred seven days after operation. No further hernia was found under intervertebral foramen. The symptoms disappeared after two weeks of symptomatic treatment such as swelling and analgesia, and he was discharged. No perioperative complications such as infection and nerve root injury occurred. Conclusion: When PELD is used to treat high-displacement LDH, the choice of transforaminal approach or interlaminar approach needs to be personalized according to the LDH segment and the direction of displacement. KEYWORDS: Spinal Surgery, Spinal Endoscopic Imaging, Inter Laminar Spine, Nucleus Pulposus Removal. doi: https://doi.org/10.12669/pjms.37.6-WIT.4880How to cite this:Chen B, Du Z. Neurological safety of spinal surgery for nucleus pulposus removal under spinal endoscopic imaging guided by inter laminar spine. Pak J Med Sci. 2021;37(6):1667-1671. doi: https://doi.org/10.12669/pjms.37.6-WIT.4880 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Full-Endoscopic Lumbar Decompression with Minimal Nerve Root Retraction for Impending Neurologic Deficit in Degenerative Lumbar Spine Diseases

Objectives The aim of this retrospective case study was to analyze the outcomes of minimal nerve root retraction in patients with impending neurologic deficit in degenerative lumbar spine disease using the full-endoscopic spine surgery. Materials and Methods Thirty-seven consecutive patients with impending neurologic deficit underwent endoscopic spine surgery through either the transforaminal or the interlaminar approach. Their clinical outcomes were evaluated with visual analog scale (VAS) leg pain score, Oswestry Disability Index (ODI), and MacNab's criteria. The outcome of motor deficitis was evaluated with the Medical Research Council (MRC) grade. Completeness of decompression was documented with a postoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan. Results A total of 40 lumbar levels of 37 patients were operated, VAS score of the leg improved from 7.7 ± 1 to 1.9 ± 0.6 (p < 0.0001). ODI score improved from 74.7 ± 6.5 to 25.4 ± 3.49 (p < 0.0001). Motor weakness improved significantly immediately after surgery. The mean MRC grade increased to 1.97, 3.65, 4.41, and 4.76 preoperatively, at 1 week, at 3 months, and at the final follow-up, respectively, and all the patients with foot drop and cauda equina syndrome symptom recovered completely. One patient with great toe drop recovered partially to MRC grade 3. Mean follow-up of the study was 13.3 ± 6.1 months. According to MacNab's criteria, 30 patients (80.1%) had good and 7 patients (18.9%) had excellent results. Three patients required revision surgery. Conclusions Minimal nerve root retraction during full-endoscopic spine surgery is safe and effective for treatment of the impending neurologic deficit. We could achieve a thorough decompression of the affected nerve root with acceptable clinical outcome and minimal postoperative morbidity.

Endoscopic Interlaminar Approach for Lumbar 4/5 Ipsilateral and Contralateral Decompression: 2-Dimensional Operative Video

Lumbar radiculopathy often results from direct compression of the exiting nerve roots. This may be caused mainly by spondylotic changes with any contribution from components like a herniated disc, facet overgrowth, and ligamentum flavum hypertrophy, or any combination of them. There are a wide range of surgical treatments directed at decompressing the neural elements. Over the last decade, endoscopic spine surgery has gained popular interest because of potential benefits, including decreased bony removal, less muscle disruption, and enhanced visualization.1 A unilateral endoscopic surgical approach can accomplish an effective bilateral decompression using the ipsilateral-contralateral technique.2 This method allows for addressing both central and bilateral recess stenoses. We present a case of a 48-yr-old female with persistent bilateral lower extremity radicular pain worse on the left side with severe lumbar 4/5 stenosis and a left-sided synovial cyst causing significant foraminal narrowing. This 2-dimensional video illustrates the technique used for an endoscopic interlaminar approach for lumbar 4/5 ipsilateral and contralateral decompression. We highlight key elements regarding the positioning, workflow, and surgical technique to successfully perform this approach. Patient consented to the procedure.