Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis
Summary
The present protocol describes the steps and key points of lumbar endoscopic unilateral laminotomy for bilateral decompression for the treatment of degenerative lumbar spinal stenosis.
Abstract
Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ligaments. LSS encompasses central canal stenosis (CCS), lateral recess stenosis (LRS), and intervertebral foramen stenosis (IFS). The utilization of lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has gained popularity in the treatment of CCS and LRS. This popularity is attributed to the rapid development of endoscopic instruments and the progress of endoscopic philosophy.
In this technical report, a detailed introduction to the steps and key points of LE-ULBD is provided. Simultaneously, a retrospective review of 132 consecutive patients who underwent LE-ULBD for central canal and/or lateral recess stenosis was conducted. The outcomes after more than two years of follow-up were assessed using the visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, and the modified MacNab criteria to evaluate surgical efficacy. All 132 patients underwent LE-ULBD successfully. Among them, 119 patients were rated as “excellent,” while 13 patients were rated as “good” based on the modified MacNab criteria during the last follow-up. Incidental dural tears occurred in four cases, but there were no post-operative epidural hematomas or infections. The experience demonstrates that LE-ULBD is a less invasive, effective, and safe approach. It can be considered as an alternative option for treating patients with lumbar central canal stenosis and/or lateral recess stenosis.
Introduction
Degenerative lumbar spinal stenosis (DLSS) can result from alterations in bony, discal, capsular, or ligamentary anatomical structures. Clinically, LSS presents with a range of symptoms, including radiating sciatic pain in the legs, neurogenic claudication during ambulation, and sensory disturbances, all of which significantly affect patients' quality of life1,2,3. An initial conservative management period of two months is the recommended therapeutic approach for LSS. If conservative measures prove ineffective, transitioning to surgical decompression therapy becomes the subsequent recommendation.
Historically, open laminectomy has been the traditional surgical approach for addressing spinal stenosis. Peer-reviewed studies have confirmed its safety and cost-effectiveness, with outcomes showing notable superiority compared to non-surgical interventions4,5,6,7,8. However, the complexities involved in achieving comprehensive bony decompression of neural components can introduce the risk of segmental spinal instability. This may lead to symptom recurrence or a subsequent need for arthrodesis9,10. Distinctively, Ghogawala et al.11 documented that approximately 34% of patients, after undergoing traditional laminectomy for lumbar spinal stenosis with concomitant stable spinal spondylolisthesis, required revision surgery within four years post-operatively.
Over the past five decades, a discernible shift toward minimally invasive spinal surgical procedures has become evident. The overarching objective has been to reduce approach-related tissue disruption and subsequently mitigate post-operative discomfort and disability. This transition aligns seamlessly with the advent and progression of percutaneous endoscopic spine surgery.
Synchronized with advancements in endoscopic technology and a deepened understanding of endoscopic anatomical intricacies, contemporary endoscopic spine surgeons are now equipped to address a spectrum of LSS presentations safely and effectively. Specifically, lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has gained traction as a favored modality for LSS management12,13,14,15,16,17(Figure 1). Paramount benefits of LE-ULBD include minimal incision requirements, avoidance of soft tissue disruption and muscular denervation, along with improved visualization.
Between May 2017 and May 2021, our institution employed the LE-ULBD technique to manage 132 patients with LSS. Relevant technical details and outcomes over a two-year follow-up period are elucidated herein. Based on these findings, LE-ULBD emerges as a minimally invasive, effective, and secure modality, positioning it as a viable alternative therapeutic strategy for patients diagnosed with lumbar central canal stenosis and/or lateral recess stenosis.
Protocol
Representative Results
Discussion
With the progressive evolution of percutaneous endoscopic spine surgery and clinicians' profound comprehension of endoscopic procedures, the therapeutic indications for endoscopic lumbar interventions have expanded to encompass all manifestations of LSS, branching out from merely addressing lumbar disc herniation. The spectrum of endoscopic management for LSS includes stenosis decompression, contralateral decompression, and fusion facilitated by endoscopic visualization. An increasing volume of research underscores t…
Declarações
The authors have nothing to disclose.
Acknowledgements
None.
Materials
| Kerrison Rongeur | Joimax GmbH, Karlsruhe, Germany | ||
| The endoscopic high-speed diamond burr | NSK-Nakanishi International, Co., Ltd., Osaka, Japan | Primado P200-RA330 | |
| The endoscopic surgical system Delta | Joimax GmbH, Karlsruhe, Germany | ||
| The radiofrequency probe | Elliquence LLC, Baldwin, New York | Trigger-FlexR Bipolar System | |
| Trephine | Joimax GmbH, Karlsruhe, Germany |
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