Transforaminal Endoscopic Decompression for Lumbar Spinal Stenosis: A Novel Surgical Technique and Clinical Outcomes

Clinical outcomes of percutaneous transforaminal endoscopic decompression for the treatment of degenerative lumbar scoliosis associated with spinal stenosis in elderly individuals: a matched comparison study

PURPOSE

This retrospective cohort study evaluated the efficacy and safety of percutaneous transforaminal endoscopic decompression (PTED) in elderly patients with degenerative lumbar scoliosis (DLS) associated with lumbar spinal stenosis (LSS).

STUDY DESIGN

A matched comparison study.

METHODS

In total, 97 patients with DLS associated with LSS who underwent PTED under local anesthesia between 2016 and 2021 were retrospectively analyzed. Using the inclusion and exclusion criteria, 24 patients aged ≥ 80 years were screened and included in the study group. Then, 24 patients aged 50-80 years were matched according to gender, date of surgery, and surgical levels were included in the control group. Clinical outcomes such as the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, modified MacNab criteria, radiological parameters, and complications were assessed. The independent sample t-test, Pearson's chi-square test and Fisher's exact test were used to compare the parameters between the study and control groups.

RESULTS

The study group had significantly higher mean American Society of Anesthesiologists classification and age-adjusted Charlson Comorbidity Index scores than the control group (2.42 ± 0.72) vs. 5.25 ± 1.03 and 1.67 ± 0.76 vs. 3.17 ± 2.10, respectively). The VAS scores for pain in two legs and back and ODI scores significantly improved at two weeks after surgery and at the final followup (p < 0.05). The study group had higher back pain VAS and ODI scores than the control group at the final followup (p < 0.05). In addition, the complication and patient satisfaction rates were similar between the two groups (p > 0.05). The overall radiological parameters were comparable between the two groups, and there was no significant deterioration in coronal imbalance or loss of disc height between the two groups.

CONCLUSION

Elderly patients (aged ≥ 80 years) with DLS associated with LSS are less fit and have a greater number of comorbidities. However, they can achieve satisfactory outcomes with PTED, which are comparable to those of patients < 80 years. PTED under local anesthesia can also be an efficient alternative to conventional open lumbar decompression surgery for treating elderly patients with comorbidities.

Full-Endoscopic Posterior Lumbar Interbody Fusion: A Review and Technical Note

Remarkable innovations in spinal endoscopic surgery have broadened its applications over the past 20 years. Full-endoscopic fusions have been widely reported, and several full-endoscopic approaches for interbody fusion have been published. In general, full-endoscopic lumbar interbody fusion (LIF) is called Endo-LIF, and facet-preserving Endo-LIF through the transforaminal route is called trans-Kambin's triangle LIF, which has a relatively longer history than facet-sacrificing Endo-LIF via the posterolateral route. Both approaches can reduce intraoperative and postoperative bleeding. However, there is a higher risk of subsidence and exit nerve root injury. There is no direct decompression in either of the interbody fusions, and additional decompression is required if there is severe lumbar bony canal stenosis. However, the posterior interlaminar approach, which is a well-known standard in full-endoscopic spine surgery, has rarely been applied in the field of endoscopic lumbar fusion surgery. Full-endoscopic posterior LIF (FE-PLIF) via an interlaminar approach can accomplish direct decompression of bony canal stenosis and safe interbody fusion. FE-PLIF via an interlaminar approach demonstrated a longer operation time, less blood loss, and shorter hospitalization duration than minimally invasive transforaminal LIF. FE-PLIF, which can accomplish direct decompression for bony spinal canal stenosis, is superior to other Endo-LIFs. However, FE-PLIF requires technical dexterity to improve efficiency and reduce technical complexity.

Percutaneous transforaminal endoscopic decompression with removal of the posterosuperior region underneath the slipping vertebral body for lumbar spinal stenosis with degenerative lumbar spondylolisthesis: a retrospective study

BACKGROUND

Percutaneous transforaminal endoscopic decompression (PTED) is an ideal minimally invasive decompression technique for the treatment of lumbar spinal stenosis (LSS) with degenerative lumbar spondylolisthesis (DLS). The posterosuperior region underneath the slipping vertebral body (PRSVB) formed by DLS is an important factor exacerbating LSS in patients. Therefore, the necessity of removing the PRSVB during ventral decompression remains to be discussed. This study aimed to describe the procedure of PTED combined with the removal of the PRSVB and to evaluate the clinical outcomes.

METHODS

LSS with DLS was diagnosed in 44 consecutive patients at our institution from January 2019 to July 2021, and they underwent PTED combined with the removal of the PRSVB. All patients were followed up for at least 12 months. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.

RESULTS

The mean age of the patients was 69.5 ± 7.1 years. The mean preoperative ODI score, VAS score of the low back, and VAS score of the leg were 68.3 ± 10.8, 5.8 ± 1.0, and 7.7 ± 1.1, respectively, which improved to 18.8 ± 5.0, 1.4 ± 0.8, and 1.6 ± 0.7, respectively, at 12 months postoperatively. The proportion of patients presenting "good" and "excellent" ratings according to the modified MacNab criteria was 93.2%. The percent slippage in spondylolisthesis preoperatively (16.0% ± 3.3%) and at the end of follow-up (15.8% ± 3.3%) did not differ significantly (p>0.05). One patient had a dural tear, and one patient had postoperative dysesthesia.

CONCLUSIONS

Increasing the removal of PRSVB during the PTED process may be a beneficial surgical procedure for alleviating clinical symptoms in patients with LSS and DLS. However, long-term follow-up is needed to study clinical effects.

The effectiveness of postoperative exercise based on gait analysis compared with conventional exercise in patients with lumbar spinal stenosis: A randomized clinical trial

BACKGROUND

Despite being used as a program of postoperative rehabilitation, few randomized controlled trials have compared the effectiveness of postoperative exercise based on gait analysis in patients with lumbar spinal stenosis (LSS).

OBJECTIVE

To investigate the effectiveness of postoperative exercise based on gait analysis in patients with LSS and to compare it with the effectiveness of conventional exercise.

METHODS

This was a double-blind, randomized clinical trial. Sixty-eight participants with LSS were randomly assigned to one of two groups. After receiving a standardized surgical procedure, the observation group received exercises based on 3-D gait analysis, and the control group received empirical physiotherapy containing 4 basic interventions. Both groups took a one-hour session twice daily for 2 weeks. The Oswestry Disability Index (ODI) scale and the Visual Analog Scale (VAS) were measured before and 2 weeks and 6 months after intervention. The gait indicators were measured before and 6 months after intervention.

RESULTS

At baseline, there were no significant differences in the ODI, VAS or absolute symmetry index (ASI) of the gait variables between the observation group and the control group. However, at 6 months, pain intensity, walking, standing, social life and summary scores of ODI and VAS of the leg demonstrated significant differences (p< 0.05, respectively) between groups, and the observation group had greater reductions in ASI of stride length, hip flexion, knee flexion and ankle dorsiflexion compared with the control group (p< 0.05, respectively).

CONCLUSIONS

The postoperative rehabilitation scheme based on gait analysis resulted in significant short- to medium-term improvements in pain intensity, walking, standing, social life and the summary score of ODI, VAS of leg and symmetry of stride length, hip flexion, knee flexion and ankle dorsiflexion compared with empirical exercise in patients with LSS.

Clinical Efficacy of Large-Channel Percutaneous Lumbar Endoscopic Decompression in the Treatment of Lumbar Spinal Stenosis Secondary to Old Compression Fractures

OBJECTIVE

We sought to explore the clinical efficacy of lumbar spinal stenosis (LSS) secondary to old vertebral compression fractures (OVCF) treatment by large-channel percutaneous endoscopic lumbar decompression.

METHODS

Medical data for a total of 17 patients diagnosed with LSS secondary to OVCF and treated with large-channel percutaneous endoscopic lumbar decompression in our institution from January 2019 to January 2021 were collected. The dural sac cross-sectional area and morphologic grading of the magnetic resonance imaging cross-sectional area were recorded. Lumbar spine stability was assessed using the White-Panjabi scoring system. Visual analog scale and Japanese Orthopaedic Association scores were used to evaluate the surgical efficacy, and the SF-36 health questionnaire was used to evaluate the quality of life of patients. Type and probability of complications were also recorded.

RESULTS

The operative segments of the enrolled patients were all in the lower lumbar spine. One-year follow-up post operation showed that the dural sac cross-sectional area was significantly enlarged compared with preoperation, and the morphologic grade was significantly improved (P < 0.05). There was no difference in White-Panjabi score between preoperation and postoperation (P > 0.05). Visual analog scale and Japanese Orthopaedic Association scores at each follow-up time point after operation were higher than those before operation and were significantly improved (P < 0.05). The SF-36 health survey score at 1 year after operation was significantly higher than that before operation (P < 0.05). The complication rate was 6%.

CONCLUSIONS

Large-channel percutaneous lumbar endoscopic decompression has an evident clinical effect in the treatment of LSS secondary to OVCF and has little effect on the stability of the lumbar spine, which is worthy of clinical application.

A Retrospective Comparative Study of Modified Percutaneous Endoscopic Transforaminal Discectomy and Open Lumbar Discectomy for Gluteal Pain Caused by Lumbar Disc Herniation

Introduction

This study aimed to demonstrate the safety and effectiveness of modified percutaneous endoscopic transforaminal discectomy (PETD) in the surgical management of single-segment lumbar disc herniation (LDH) gluteal pain and to determine whether it provides a better clinical outcome than open lumbar discectomy (OD).

Methods

A retrospective analysis of patients treated with modified PETD and OD for gluteal pain in LDH from January 2015 to December 2020 was conducted. Sample size was determined using a priori power analysis. Demographic information, surgical outcomes including procedure time (minutes), intraoperative blood loss (mL), hospital days, costs (RMB), fluoroscopy shots, recurrence and complications, etc., were recorded and analyzed. Prognostic outcomes were assessed using the visual analog scale (VAS), the Oswestry Disability Index (ODI), the Japanese Orthopedic Association Score (JOA) and modified MacNab criteria. The preoperative and postoperative VAS, ODI and JOA scores were recorded by two assistants. When the results were inconsistent, the scores were recorded again by the lead professor until all scores were consistently recorded in the data. MRI was used to assess radiological improvement and all patients received follow-ups for at least one year.

Results

The sample size required for the study was calculated by a priori analysis, and a total of 72 participants were required for the study to achieve 95% statistical test power. A total of 93 patients were included, 47 of whom underwent modified PETD, and 46 of whom underwent OD. In the modified PETD intragroup comparison, VAS scores ranged from 7.14 ± 0.89 preoperatively to 2.00 ± 0.58, 2.68 ± 0.70, 2.55 ± 0.69, 2.23 ± 0.81, and 1.85 ± 0.72 at 7 days, 1 month, 3 months, 6 months, and 12 months postoperatively. Patients showed significant pain relief postoperatively (P &lt; 0.01). According to the modified MacNab score, the excellent rate in the PETD group was 89.36%. There was no significant difference compared to the OD group (89.13%, P &gt; 0.05). Complication rates were lower (P &gt; 0.05) but recurrence rates were higher (P &gt; 0.05) in the modified PETD group than in the OD group. The modified PETD group had a faster operative time (P &lt; 0.01), shorter hospital stay (P &lt; 0.01), less intraoperative bleeding (P &lt; 0.01), and less financial burden to the patient (P &lt; 0.01) than the OD group. At 7 days postoperatively, the VAS score for low back pain was higher in the OD group than in the modified PETD group (P &lt; 0.01). The VAS and JOA scores at 1, 3, 6, and 12 months postoperatively were not significantly different between the modified PETD and OD groups (P &gt; 0.05), and the ODI was significantly different at 3 months postoperatively (P &lt; 0.05).

Conclusion

Modified PETD treatment is safe and effective for gluteal pain due to L4/5 disc herniation and has the advantages of a lower complication rate, faster postoperative recovery, shorter length of stay, fewer anesthesia risks and lower cost of the procedure compared with OD. However, modified PETD has a higher recurrence rate.

Comparison of Percutaneous Transforaminal Endoscopic Decompression and Transforaminal Lumbar Interbody Fusion in the Treatment of Single-Level Lumbar Disc Herniation with Modic Type I Changes

Background

Modic changes (MC) are generally considered to be related to degenerative disc disease, and there is no uniform standard for surgical methods for lumbar disc herniation (LDH) accompanied by Modic type I changes (MC I). The purpose of this study was to observe the clinical results of percutaneous transforaminal endoscopic decompression (PTED) and transforaminal lumbar interbody fusion (TLIF) for treatment of LDH accompanied by MC I.

Methods

Of the 53 consecutive patients included, 29 underwent PTED and 24 underwent TLIF. All patients were followed up for at least 24 months. Preoperative demographic characteristics, perioperative outcomes, and clinical outcomes were recorded. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, and modified Macnab criteria were used to assess clinical results.

Results

The mean age was 53.7±9.2 years in the PTED group and 53.6±9.6 years in the TLIF group. The scores of VAS legs, VAS back and ODI in the two groups after operation were significantly improved compared with those before operation (P<0.05). Notably, the VAS back pain score and ODI in the PTED group showed an increasing trend with time. And the VAS back pain scores and ODI of the two groups were statistically different at 1 year and 2 years postoperatively (P<0.05). In addition, compared with the TLIF group, the PTED group showed less operation time, blood loss, and postoperative hospital stay (P<0.05). At the final follow-up, the excellent rates were 91.7% and 86.2% in the fusion and PTED groups, respectively.

Conclusion

Both PTED and TLIF procedures significantly improved the clinical symptoms of single-level LDH patients with MC I. Compared with TLIF, MC I may affect the improvement of low back pain and functional status after PTED.

Percutaneous transforaminal endoscopic discectomy for different types of lumbar disc herniation: A retrospective study

Objective

To introduce the concept of ‘nerve root as the core’ and to investigate the surgical procedure and curative effect of percutaneous translaminar endoscopic discectomy (PTED) surgery in the treatment of different types of lumbar disc herniation (LDH).

Methods

This retrospective study analysed the clinical data from patients with LDH that underwent single-segment PTED surgery. They were divided into three groups based on LDH location: central canal zone group, lateral recess zone group and foraminal/far lateral zone group. Different working cannula placement methods were used for the different types of LDH. All patients were followed for at least 12 months. Clinical and follow-up data were compared between the three groups.

Results

A total of 130 patients were enrolled in the study: 44 (33.8%) in the central canal zone group, 72 (55.4%) in the lateral recess zone group and 14 (10.8%) in the foraminal/far lateral zone group. All three groups of patients achieved good postoperative results. The improvements in leg pain and disability were most marked in the first postoperative month in all three groups.

Conclusion

PTED achieved adequate decompression for different types of LDH. The concept of ‘nerve root as the core’ facilitated the accurate placement of the working cannula.

Comparison of percutaneous transforaminal endoscopic decompression and short-segment fusion in the treatment of elderly degenerative lumbar scoliosis with spinal stenosis

BACKGROUND

Degenerative lumbar scoliosis (DLS) combined with spinal stenosis is increasingly being diagnosed in the elderly. However, the appropriate surgical approach remains somewhat controversial. The aim of this study was to compare the results of percutaneous transforaminal endoscopic decompression (PTED) and short-segment fusion for the treatment of mild degenerative lumbar scoliosis combined with spinal stenosis in older adults over 60 years of age.

METHODS

Of the 54 consecutive patients included, 30 were treated with PTED and 24 were treated with short-segment open fusion. All patients were followed up for at least 12 months (12-24 months). Patient demographics, and perioperative and clinical outcomes were recorded. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, and modified Macnab criteria were used to assess clinical outcomes. At the same time, changes in disc height, segmental lordosis, coronal Cobb angle, and lumbar lordosis were compared.

RESULTS

The mean age was 68.7 ± 6.5 years in the PTED group and 66.6 ± 5.1 years in the short-segment fusion group. At 1 year postoperatively, both groups showed significant improvement in VAS and ODI scores compared with preoperative scores (p < 0.05), with no statistically significant difference between groups. However, VAS-Back and ODI were lower in the PTED group at 1 week postoperatively (p < 0.05). According to the modified Macnab criteria, the excellent rates were 90.0 and 91.6% in the PTED and short-segment fusion groups, respectively. However, the PTED group had a significantly shorter operative time, blood loss, postoperative hospital stay, postoperative bed rest, and complication rate. There was no significant difference in radiological parameters between the two groups preoperatively. At the last follow-up, there were significant differences in disc height, segmental lordosis at the L4-5 and L5-S1 levels, and Cobb angle between the two groups.

CONCLUSION

Both PTED and short-segment fusion for mild degenerative lumbar scoliosis combined with spinal stenosis have shown good clinical results. PTED under local anesthesia may be an effective supplement to conventional fusion surgery in elderly patients with DLS combined with spinal stenosis.

Percutaneous Transforaminal Endoscopic Decompression for Lumbar Lateral Recess Stenosis

Objective: The aim of this study was to evaluate the treatment efficacy of lateral spinal stenosis through the decompression of the nerve root under a multiple planar endoscope.

Methods: From January 2017 to March 2019, 52 patients with lumbar spinal stenosis or lumbar spinal stenosis combined with intervertebral disc herniation had been treated via transforaminal approach spinal endoscopy. Our study retrospectively analyzed the treatment outcome. All patients experienced complications with different degrees of facet joint hyperplasia and ligamentum flavum hyperplasia and hypertrophy. Some patients suffered disc herniation. All patients were treated with percutaneous transforaminal approach multiple planar endoscopic decompression. The visual analog scale (VAS) and the Oswestry Disability Index (ODI) were compared before and after the operation, as were the horizontal foramen areas of the medial margins of the upper and lower pedicles of the vertebral arch. The treatment effectiveness was evaluated.

Results: VAS and ODI scores were significantly improved at postoperative 3 days, 3 months, 6 months, and the last follow-up (P < 0.05). The area of the intervertebral foramen was 422.5 ± 159.2 mm² preoperatively and 890.8 ± 367.7 mm² postoperatively, the difference was statistically significant (P < 0.05).

Conclusion: Percutaneous transforaminal approach multiple planar endoscopic decompression could achieve an accurate and effective decompression of the lumbar lateral spinal canal. This procedure has good short-term effects, and is especially suitable for elderly patients.

Percutaneous Endoscopic Unilateral Laminotomy and Bilateral Decompression for Lumbar Spinal Stenosis

To introduce a new surgery, percutaneous endoscopic unilateral laminotomy and bilateral decompression (Endo-ULBD) using visual trepan, and investigate its efficacy and safety in elderly patients with lumbar spinal stenosis. In our retrospective study, a total of 69 patients were enrolled between March 2018 and September 2018; 31 patients were treated with Endo-ULBD and 38 patients were treated with posterior lumbar interbody fusion surgery (PLIF). The operation time, intraoperative blood loss, and hospitalization duration were compared between the two groups. A visual analog scale (VAS) was used to evaluate the degree of pain. The Oswestry Disability Index (ODI) and European Quality of Life-5 Dimensions (EQ-5D) were used to evaluate lumbar function and quality of life, respectively. Lumbar X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) were performed postoperatively at different time points. MacNab's outcome assessment and perioperative complications were also documented. The surgeon completed all surgeries successfully, and all 69 patients were followed up. The operative time of the Endo-ULBD group was 60.68 ± 0.47 min, while that of the PLIF group was 120.23 ± 10.24 min. The operative time of the Endo-ULBD group was shorter than that of the PLIF group, and the difference was statistically significant (P < 0.001). The volume of intraoperative blood loss was 47.25 ± 0.43 mL in the Endo-ULBD group and 256.90 ± 20.83 mL in the PILF group (P < 0.001). The length of hospital stay in the Endo-ULBD group was 5.12 ± 1.60 days and that in the PILF group was 10.54 ± 1.82 days (P < 0.001). The VAS scores at postoperative 1 day, 3 months, 6 months, final follow-up (Endo-ULBD: 6.58 ± 0.65, 4.55 ± 0.54, 2.78 ± 0.24, 1.31 ± 0.78; PLIF: 7.19 ± 1.14, 4.80 ± 0.13, 2.71 ± 0.83, 1.29 ± 0.56) were significantly improved compared with those before surgery (Endo-ULBD: 8.63 ± 0.37; PLIF: 8.31 ± 1.34). The ODI and EQ-5D scores of lumbar function and quality of life at each time point after surgery (Endo-ULBD ODI: 30.29% ± 0.47%, 23.35% ± 0.95%, 19.45% ± 0.81%, 10.84% ± 0.36%; EQ-5D: 0.38 ± 0.15, 0.45 ± 0.17, 0.63 ± 0.14, 0.71 ± 0.20; PLIF ODI: 33.56% ± 1.58%, 25.69% ± 2.69%, 20.01% ± 1.49%, 10.72% ± 0.29%; EQ-5D: 0.33 ± 0.03, 0.39 ± 0.05, 0.62 ± 0.07, 0.72 ± 0.10) were significantly improved compared with those before surgery (Endo-ULBD: 44.56 ± 1.32, 0.33 ± 0.07; PLIF: 43.79 ± 1.91, 0.31 ± 0.09, respectively), with statistically significant differences (P < 0.05); however, there was no significant difference between the two groups at the last follow-up (P > 0.05). At the last follow-up, the excellent and good efficacy rate was 90.3% (28/31) in the Endo-ULBD group and 89.4% (34/38) in the PILF group (χ² = 0.089, P = 0.993). No mortality, irreversible nerve injury, or even paralysis occurred in either group. Endo-ULBD for lumbar spinal stenosis has the advantages of less trauma, a shortened operation time, and rapid recovery and is an effective alternative for the treatment of lumbar spinal stenosis. Strict surgical indications, reasonable surgical plans, and experienced surgeons are important factors to ensure safety and satisfactory postoperative efficacy.

Is Decompression and Partial Discectomy Advantageous Over Decompression Alone in Microendoscopic Decompression Of Monosegmental Unilateral Lumbar Recess Stenosis?

BACKGROUND

Endoscopic techniques are well accepted as surgical technique for decompression of lumbar lateral recess stenosis (LRS). It is uncertain if there is a difference in clinical outcome for decompression alone (DA) or decompression with partial discectomy (DPD) for the treatment of LRS.

METHODS

All files of patients who underwent an endoscopic procedure for lumbar LRS were identified from a prospectively collected database. Preoperative magnetic resonance imaging and endoscopic video were analyzed with special focus on the technique of nerve root decompression. Clinical outcome was assessed via a personal examination, a standardized questionnaire including the numeric rating scale (NRS) for leg and back pain, the Oswestry disability index (ODI), and the modified MacNab criteria to assess functional outcome and clinical success.

RESULTS

Sixty-six patients were identified of which 57 attended for evaluation (86.4%). DA was performed in 15 (26.3%) patients and DPD in 42 patients (73.7%). The mean follow-up was 45.0 months (range: 16-82 months). Fifty-two patients reported to be free of leg pain (91.1%), 42 patients had no noticeable back pain (73.7%), 49 patients had full muscle strength (85.9%), and 48 patients had no sensory disturbance (84.2%). The mean NRS for leg pain was 1, the mean NRS for back pain was 2, mean ODI was 16% (range: 0%-60%). Clinical success was noted in 49 patients (85.9%) and it was significantly higher for patients following DPD (P = .024). The overall repeat procedure rate was 12% with reoperation rate at the index segment in 10.5% of cases. There were no significant differences with respect to leg and back pain, ODI, and reoperation between both groups.

CONCLUSION

Microendoscopic DPD of LRS achieves a 92% clinical success rate which is significantly higher compared to 67% clinical success achieved by DA. There was no significant difference for the rate of reoperation, leg and back pain, and ODI.

LEVEL OF EVIDENCE

4.

Clinical outcomes of transforaminal endoscopic lateral recess decompression by using the visualized drilled foraminoplasty and visualized reamed foraminoplasty: a comparison study

Background

Lateral recess stenosis (LRS) is a common degenerative disease in the elderly. Since the rise of comorbidity is associated with increasing age, transforaminal endoscopic lateral recess decompression (TE-LRD) is advocated. The objective of this study was to compare the clinical outcomes of TE-LRD in patients with LRS via visualized drilled foraminoplasty (VDF) or visualized reamed foraminoplasty (VRF) technique.

Methods

A total of 45 and 42 consecutive patients with limp or unilateral radiculopathy symptoms underwent TE-LRD using the VDF and VRF technique, respectively. The radiation exposure and operation time, time to return to work, and complications were compared between two groups. Their clinical outcomes were evaluated with the visual analogue scale (VAS) leg pain score, VAS back pain score, Oswestry Disability Index (ODI) and modified MacNab’s criteria.

Results

The average values of radiation exposure and operative time in the VDF group were significantly higher than those in the VRF group (P <  0.05). The postoperative VAS and ODI scores in both groups were significantly improved compared with those before the operation (P <  0.05). In addition, the VAS score of the leg pain and ODI score in the VRF group were significantly lower than those in the VDF group at the 1-week follow-up (P <  0.05). The good-to-excellent rates of the VDF group and VRF group were 88.89 and 90.48%, respectively, whereas the complication occurrence rates were 6.67 and 4.76% in the VDF group and VRF group, respectively.

Conclusions

TE-LRD performed by using VRF technique can be applied to treat LRS safely and effectively with short radiation exposure and operation time. This technique was comparable to the VDF technique with improved VAS leg pain and ODI scores in the short period after the operation. However, potential complications and risks still need to be considered.

Degenerative central lumbar spinal stenosis: is endoscopic decompression through bilateral transforaminal approach sufficient?

BACKGROUND

At present, few reports of percutaneous endoscopic transforaminal decompression surgery have been reported to solve central lumbar spinal stenosis (CLSS). Is endoscopic decompression through bilateral transforaminal approach decompression sufficient for degenerative CLSS?

METHODS

This retrospective study included 47 cases of CLSS patients who underwent percutaneous endoscopic decompression through bilateral transforaminal approach. Clinical outcomes such as ODI, back and leg VAS, the Macnab criteria were evaluated. Surgical results including operative time, postoperative hospital stay, recurrence, and surgical complications were also studied. Radiologically, lumbar stability was assessed and lumbar dural sac dimension was compared preoperatively and postoperatively.

RESULTS

All 47 patients were followed up. The average follow-up period was 24.5 months. The average operation time was 116 min. The mean VAS of leg and back pain, and the mean ODI improved from 7.81, 2.53, and 77.03% at baseline to a final 1.94 (P = 0.00), 2.47 (P = 0.71), and 19.40% (P = 0.00), respectively. According to the Macnab criteria, 97.9% of patients achieved excellent and good results. There were 2 cases of dural tear and 3 cases of transient postoperative dysthesia. The cross-sectional area of the dural sac was significant enlargement at the last fellow up (74.28 ± 13.08 mm² vs.104.91 ± 12.40 mm², P = 0.00).

CONCLUSIONS

Except for the main pathogenic factors on the dorsal side of the dural sac, percutaneous endoscopic decompression through a bilateral transforaminal approach is sufficient for CLSS. It is a feasible, safe, and clinically effective minimally invasive procedure.

Linical efficacy of percutaneous endoscopic lumbar discectomy for the treatment of lumbar spinal stenosis in elderly patients: a retrospective study

Background

Although percutaneous endoscopic lumbar discectomy (PELD) is increasingly being used to treat lumbar degenerative disease, the treatment of elderly patients with lumbar spinal stenosis (LSS) involves considerable uncertainty. The purpose of this study was to evaluate the safety and effectiveness of PELD for the treatment of LSS in elderly patients aged 65 years or older.

Methods

In this retrospective review, 136 patients aged 65 years or older who underwent PELD to treat LSS were evaluated. The patients were divided into two groups, group A (ages 65–74) and group B (age ≥ 75), and perioperative data were analyzed. The Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and MacNab classification were used to evaluate postoperative clinical efficacy.

Results

All patients successfully underwent the operation with satisfactory treatment outcomes. Compared to preoperative scores, the self-reported scores or pain while performing daily activities were significantly improved in both treatment groups (P < 0.05). No statistically significant between-group differences were observed in operation time, intraoperative blood loss, postoperative bed rest, and postoperative hospital stay (P > 0.05). The overall postoperative complication rate was similar between the two groups. Moreover, no statistically significant differences in VAS-back pain scores, VAS-leg pain scores, JOA scores, and MacNab classification were found between the groups at the 3-month and 1.5-year follow-up examinations (P > 0.05).

Conclusion

PELD is safe and effective for the treatment of LSS in elderly patients. Age is not a contraindication for decompressive lumbar spine surgery. PELD has advantages such as reduced trauma, fewer anesthesia-related complications, and a fast postoperative recovery. Elderly patients should be considered good candidates for lumbar decompression surgery using minimally invasive techniques.

Percutaneous Transforaminal Endoscopic Decompression for Geriatric Patients with Central Spinal Stenosis and Degenerative Lumbar Spondylolisthesis: A Novel Surgical Technique and Clinical Outcomes

Purpose

Percutaneous transforaminal endoscopic decompression (PTED) is an ultra-minimally invasive surgical option for patients that does not involve the same amount of destabilizing facet joint removal as a traditional laminectomy. The objective of this study was to describe the procedure of PTED under local anesthesia for geriatric patients with central spinal stenosis and degenerative lumbar spondylolisthesis (CSS-DLS).

Materials and Methods

From January 2016 to December 2018, 30 consecutive geriatric patients who underwent surgery for single-level CSS-DLS were retrospectively reviewed. All patients were followed for at least 12 months (12–24 months). The visual analog scale (VAS) scores, Oswestry disability index (ODI) scores and modified MacNab criteria were used to evaluate the clinical results.

Results

The mean age was 73.1±6.0 years. Follow-up ranged from 12 to 36 months. The mean±SD values of the preoperative VAS for leg pain and ODI were 7.4±1.0 and 67.2±8.4, respectively. The values improved to 2.2±1.1 and 19.9±8.1 at 12 months postoperatively. The outcomes of the modified MacNab criteria showed that 93.3% of patients obtained a good-to-excellent rate. The percent slippage of spondylolisthesis before surgery (13.8±2.5%) and at the end of follow-up (14.0±2.5%) was not significantly different.

Conclusion

PTED under local anesthesia could be a useful supplement to traditional decompression in geriatric patients with CSS-DLS.

A Historical Review of Endoscopic Spinal Discectomy

As an essential component of minimally invasive spine surgery, endoscopic spine surgery (ESS) has continuously evolved and has been accepted as a practical procedure by the worldwide spine community. Especially for lumbar disc herniation (LDH), the percutaneous endoscopic or full-endoscopic discectomy technique has been scientifically proven through randomized controlled trials and meta-analyses to be a good alternative to open discectomy. The initial concept of endoscopic spine discectomy was concerned with indirect disc decompression using various instruments such as blind forceps, a nucleotome, laser, radiofrequency coblation, and some chemical agents. The main surgical field has been shifted from the intradiscal space to the epidural space. Precise and selective discectomy for extruded LDH in the epidural space under high-quality endoscopic visualization is now feasible. Furthermore, the medical applications of ESS is broadening to include spinal stenosis, segmental instability, infection, and even intradural lesions. In this review article, I describe the history of endoscopic spine discectomy and decompression techniques, as well as evolution of the paradigm. This history may help indicate the future of practical ESS.

Uniportal Endoscopic Lumbar Interbody Fusion

The cause of radiculopathy is the compression of the nerve root which can be secondary to sliding of the vertebra and reduced disc height. In some patients, decompression alone does not resolve this problem. We describe the uniportal endoscopic transforaminal lumbar interbody fusion technique. Full-endocopic foraminotomy and discectomy are followed by cage implementation and percutaneous instrumentation. The goal of this surgical method is decompression of nerve roots, segment stabilization, disc height, and sagittal alignment restoration. Uniportal endoscopic facet sparing transforaminal transkambin lumbar interbody fusion is a good surgical option to treat degenerative disc disease, mechanical instability, and spondylolisthesis. This method shows favourable clinical outcomes in selected patients.

A Narrative Review of Development of Full-Endoscopic Lumbar Spine Surgery

In the first phase of development of lumbar endoscopic spine surgery, the focus was on removal of soft disc material through the working corridor of Kambin’s triangle using transforaminal endoscopic lumbar discectomy. With the introduction of the interlaminar approach and increased interest from both industry and surgeons, there has been an exponential development of endoscopic surgical equipment and a corresponding expansion of endoscopic techniques. Endoscopic treatment strategies are applied to conditions ranging from contained prolapsed intervertebral discs to noncontained migrated herniated discs, hard calcified discs, spinal stenosis in the central or lateral recess and the foraminal and extraforaminal region, and other combinations of degenerative conditions requiring decompression or fusion surgery. The further expansion of endoscopic surgical management involving complicated spinal cases and the final quartet of trauma, infections, tumors, and possibly deformities could be the future stage of endoscopic spine surgery development. This article covers the full range of current treatment strategies and presents possible future developments of endoscopic spine surgery for the management of lumbar spinal conditions.

Transforaminal Endoscopic Discectomy for Hard or Calcified Lumbar Disc Herniation: A New Surgical Technique and Clinical Outcomes

OBJECTIVE

Hard or calcified discs are often adherent to surrounding nerve tissue. The whole herniated disc is difficult to remove by pulling part of the hernia mass, which makes obtaining good results through endoscopic treatment difficult. The purpose of this study was to describe the details of the transforaminal endoscopic lumbar discectomy technique for a hard or calcified disc and report the clinical results.

METHODS

From October 2016 to June 2019, 43 consecutive cases diagnosed as hard or calcified lumbar disc herniation at our institution and treated with transforaminal endoscopic discectomy were evaluated. Endoscopic decompression was performed in patients with hard or calcified lumbar disc herniation.

RESULTS

The preoperative visual analog scale score for leg pain (mean ± standard deviation) was 7.09 ± 1.74. The score improved to 2.55 ± 1.35 at 1 week postoperatively, 1.88 ± 1.29 at 4 weeks postoperatively, and 1.58 ± 1.0 at 26 weeks postoperatively (P < 0.01 for all). The preoperative Oswestry Disability Index (mean ± standard deviation) was 55.4 ± 23.04, which improved to 30.89 ± 13.64 at 1 week postoperatively, 23.08 ± 11.64 at 4 weeks postoperatively, and 16.42 ± 9.76 at 26 weeks postoperatively (P < 0.01 for all). Two patients developed a dural laceration. Both patients were discharged after several hours of observation. None of the patients had postoperative infection, epidural hematoma, or delayed neurological deterioration.

CONCLUSIONS

Transforaminal endoscopic discectomy could be an effective treatment method for a selected group of patients with hard or calcified lumbar disc herniation.

The Therapeutic Evaluation of Spinal Canal Decompression by Using the TBEIS Technique in the Treatment of Lumbar Spinal Stenosis

Objective

To evaluate the clinical efficacy of the percutaneous endoscopic Transforaminal Broad Easy Immediate Surgery (TBEIS) technology in elderly patients with lumbar spinal stenosis (LSS).

Methods

From February 2016 to May 2018, 35 elderly patients with LSS were treated with the TBEIS technique. There were 23 males and 12 females, aged from 53 to 72 years with a median age of 63.1 years. Preoperative, 1 day, and 1 and 12 months postoperative visual analogue scale (VAS) scores and Oswestry Disability Index (ODI) were statistically analyzed. The modified MacNab criterion was used to assess the clinical effects. The radiological outcomes were evaluated by X-ray and computed tomography (CT).

Results

All of the operations were successful. The operative time ranged from 120 to 170 min with a median time of 148 min. All of the patients were followed up for 12 to 38 months with a median follow-up of 18 months. Preoperative, 1 day, and 1 and 12 months postoperative VAS leg scores were 6.91 ± 0.98, 1.69 ± 0.68, 1.23 ± 0.59, and 0.91 ± 0.61, respectively, and the VAS back scores improved from 4.51 ± 0.82 to 0.66 ± 0.68. The ODI scores were 63.82 ± 7.59, 38.79 ± 6.36, 24.79 ± 3.90, and 11.33 ± 3.92, respectively. Postoperative scores of VAS and ODI were obviously improved (P < 0.01). According to the modified MacNab criteria used to evaluate the clinical effects, 11 cases achieved excellent results, 18 cases achieved good results, 4 cases achieved fair results, and 2 cases achieved poor results. There were no neurovascular injury and other complications.

Conclusions

Treatment of LSS in the elderly patients by the TBEIS technology has good clinical efficacy, and the technique is safe and minimally invasive.

Percutaneous transforaminal endoscopic decompression for lumbar spinal stenosis with degenerative spondylolisthesis in the elderly

OBJECTIVES

Percutaneous transforaminal endoscopic decompression (PTED) under local anesthesia is rarely performed for lumbar spinal stenosis (LSS) with degenerative lumbar spondylolisthesis (DLS) because of the limited field of vision, inherent instability, etc. The objective of this study was to describe the procedure of the PTED technique and to demonstrate the early clinical outcomes.

PATIENTS AND METHODS

From January 2017 to January 2019, 40 consecutive patients aged 60 and older were diagnosed with LSS with DLS in our institution and underwent PTED. All patient were followed up to 1 year postoperatively. The clinical outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria.

RESULTS

The mean age was 70.2 ± 7.1 years. Follow-up ranged from 12 to 24 months. The mean ± SD values of the preoperative VAS leg pain and ODI scores were 7.5 ± 1.1 and 67.3 ± 9.3, respectively. The scores improved to 2.2 ± 1.1 and 20.7 ± 8.1 at 12 months postoperatively. The outcomes of the modified MacNab criteria showed that 87.5 % of patients obtained a good-to-excellent rate. The percent slippage of spondylolisthesis before surgery (10.8 ± 2.6 %) and at the end of follow-up (11.0 ± 2.4 %) was not significantly different. One patient had a dural tear and intracranial hypertension, and one patient had tibialis anterior weakness.

CONCLUSION

PTED under local anesthesia could be an effective treatment method for LSS with DLS in elderly patients. However, potential complications still require further evaluation.

[The application of classification of lateral region of lumbar spinal canal for treatment of lumbar spinal stenosis in geriatric patients using full endoscopic transforaminal decompression surgery]

OBJECTIVE

To assess the reliability, effectiveness, and the safety of full endoscopic transforaminal decompression (FETD) under local anesthesia guided by the classification of lateral region of the lumbar spinal canal (CLLSC) in treating lumbar spinal stenosis (LSS) in geriatric patients.

METHODS

The clinical data of 63 geriatric patients with LSS met the inclusion criteria underwent FETD surgery between June 2015 and July 2017 were retrospectively analyzed. There were 37 males and 26 females, with a median age of 76 years [interquartile range (IQR), 73-80 years], and a median symptomatic duration of 55 months (IQR, 16-120 months). There were 17 cases of grade B and 46 cases of grade C based on the Schizas morphological grading system. CLLSC was used for imaging evaluation for the stenotic condition, and intra-class correlation coefficients (ICC) were used to test intra-observer and inter-observer reliability of CLLSC. The stenotic condition of patients was re-evaluated by the surgeon after operation, and the results were compared with the findings of preoperative CLLSC. The visual analogue scale (VAS) score for low back pain and leg pain recorded before operation, and at 1 day, 3 months, and 6 months after operation, and last follow-up were used to assess the pain relieving; the functional improvement was evaluate by Oswestry disability index (ODI); the modified Macnab criteria were used to self-evaluate the surgical satisfaction.

RESULTS

The operation were successfully performed for all patients, with a median operation time of 75 minutes (IQR, 65-85 minutes), postoperative hospitalization stay of 48 hours (IQR, 48-72 hours), and the time to ambulation after operation of 24 hours (IQR, 24-24 hours). Sixty-three patients were followed-up and with a median follow-up time of 18 months (IQR, 13-20 months). Based on preoperative CLLSC classification, there were 72 stenotic zones, distributed 16 in zone 1, 6 in zone 2, 3 in zone 3, 2 in zone 4, 7 in zone 5, 34 in zones 1+2, 2 in zones 3+4, and 2 in zones 4+5. Perioperative complications occurred in 4 cases (6.3%), including 2 cases of intraoperative dural sac tear, 1 of preoperative numbness symptom aggravation, and 1 of postoperative urinary retention. VAS score of leg pain and ODI score at each time point after operation were significantly improved compared with those before operation ( P<0.05). VAS scores of low back pain showed no significant difference between pre- and post-operation ( P>0.05). At last follow-up, based on the modified Macnab criteria, 19 cases were excellent, 37 were good, 6 were fair, and 1 was poor, and the excellent and good rate was 88.9%. The reliability analysis showed that CLLSC had substantial intra-observer reliability in the geriatric population, with an average ICC of 0.78. There was also a substantial inter-observer reliability, with an average ICC of 0.73. While comparing the preoperative CLLSC results with the postoperative CLLSC results, 53 patients (73.6%) were in full agreement, 15 patients (20.8%) were in partial agreement, and 4 patients (5.6%) were not.

CONCLUSION

CLLSC has high reliability in the diagnosis of LSS in the geriatric patients. Combined FETD with CLLSC, accurate diagnosis, and minimal invasion can be performed to achieve safe and effective result.

Efficacy of percutaneous transforaminal endoscopic decompression treatment for degenerative lumbar spondylolisthesis with spinal stenosis in elderly patients

The efficacy of fusion combined with decompression for the treatment of spinal stenosis with degenerative lumbar spondylolisthesis (DLS) has been debated. Percutaneous transforaminal endoscopic decompression (PTED) under local anesthesia is an ultra-minimally invasive procedure. The present study aimed to evaluate whether PTED is an effective alternative therapy for spinal stenosis associated with DLS in elderly patients. PTED was performed in elderly patients exhibiting lumbar stenosis and low-grade (Meyerding grades I and II) DLS; these patients also exhibited leg-dominant symptoms and had tolerable or absent mechanical back pain. Administration of general anesthesia may be considerably hazardous in patients when combined with comorbid conditions that result from aging. Therefore, the present procedure was performed under local anesthesia. No obvious radiographic lumbar intervertebral instability was identified prior to surgery. Pre- and post-operative visual analogue scale (VAS) score, Oswestry Disability Index (ODI) and walking distance data were collected. The clinical global outcomes following surgery were evaluated using modified MacNab criteria. A total of 18 elderly patients underwent surgery using PTED techniques. The mean follow-up time was 27.7 months (range, 24-33 months) and the mean estimated blood loss was 18.33 ml (range, 10-35 ml). The mean pre-operative ODI, VAS score of the back and VAS score of the leg were 68.2±6.5, 2.8±1.4 and 6.6±1.2, respectively. All average scores improved post-operatively to 31.7±5.2, 1.5±0.6 and 1.7±0.8, respectively, at the latest follow-up. A statistically significant improvement was observed for all scores at 1 month and that the scores remained relatively stable after that. According to modified MacNab criteria, the good-to-excellent rate was 83.3%. Only 1 patient required micro-decompression surgery due to poor rating. The present study indicated that PTED may be an effective alternative therapeutic option for elderly patients with low-grade DLS associated with spinal stenosis. However, PTED techniques continue to evolve and further follow-up studies are required to determine the long-term outcomes of this treatment technique.

Learning curve and clinical outcomes of percutaneous endoscopic transforaminal decompression for lumbar spinal stenosis

PURPOSE

To define and analyze the learning curve of percutaneous endoscopic transforaminal decompression (PETD) for lumbar spinal stenosis (LSS).

METHODS

From July 2015 to September 2016, 78 patients underwent PETD; one of whom was converted to open surgery, two were lost, and 75 were included in this study. Clinical results were assessed by using the Oswestry Disability Index (ODI) and visual analog scale (VAS). The learning curve was assessed by a logarithmic curve-fitting regression analysis. Of these 75 patients, 35 were defined as the "early" group, and 40 were defined as the "late" group for comparison.

RESULTS

The mean follow-up was 25.37 ± 4.71 months. The median operative time gradually decreased from 95 (interquartile range, IQR, 85-110) minutes for the early group to 70 (IQR, 60-80) minutes for the late group (P < .000), and an asymptote was reached after approximately 35 cases. After surgery, the VAS for leg pain (LP) and ODI decreased significantly and remained constant during the follow-up. However, the VAS of low back pain (LBP) increased mildly. The total complication rate was 6.6%. ODI, VAS of LP and of LBP, and complication rate did not significantly differ between two groups. Early ambulation and short hospital stay after surgery were achieved.

CONCLUSION

The learning curve of PETD for LSS was assessed and good clinical results were achieved. The surgeon's experience with this technique correlated with reduced operation time. Proper patient selection, familiarity with pathological anatomy, and manipulation under endoscopic view may shorten the learning curve and decrease complications.

[Short-term effectiveness of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis]

Objective

To observe the effectiveness and safety of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis.

Methods

A retrospective analysis of 44 patients with single-segment severe central lumbar spinal stenosis with bilateral lower extremity symptoms between October 2015 and December 2017 was performed. Among them, 36 cases underwent bilateral decompression through bilateral transforaminal approach, and 8 cases underwent bilateral decompression through unilateral transforaminal approach. There were 25 males and 19 females, the age ranged from 56 to 89 years with an average of 68.6 years. The disease duration was 5-39 months with an average of 14.5 months. Involved segments: L _{3, 4} in 6 cases, L _{4, 5} in 33 cases, and L ₅, S ₁ in 5 cases. The dural sac cross-sectional area (DSCA) of the MRI was (66.36±8.48) mm ². Morphological grading (MG) classification: 29 cases of grade C, 15 cases of grade D. The visual analogue scale (VAS) score of preoperative low back pain was 2.3±1.0 and the VAS score of lower extremity pain was 7.8±1.2; the Oswestry disability index (ODI) was 77.8±7.3. Postoperative VAS scores, ODI scores, MG classification, and DSCA were recorded and compared with preoperative ones, and clinical outcomes were assessed by using the modified MacNab criteria.

Results

All patients successfully underwent surgery and the wounds healed by first intention. All 44 patients were followed up 13-46 months with an average of 24.8 months. One patient developed postoperative lower extremity paralysis and 1 patient developed a dural tear. There was no infection, recurrence, or revision surgery during the follow-up. Postoperative imaging showed that the central spinal canal was enlarged and the area of the dural sac was significantly increased compared with preoperative one. The VAS score of low back pain was 2.4±0.6 and 2.5±0.8 at 1 month after operation and at last follow-up, showing no significant difference when compared with preoperative scores ( P>0.05). The VAS of lower limb pain was 2.1±0.6 and 2.0±1.1 at 1 month after operation and at last follow-up, which was significantly improved when compared with preoperative scores ( P<0.05); but no significant difference was found between at 1 month after operation and at last follow-up ( P>0.05). At last follow-up, the ODI score was 19.7±6.4, and the DSCA was (104.93±12.56) mm ², which was significantly improved when compared with preoperative values ( P<0.05). The MG classification was also significantly higher than preoperative one ( Z=-5.789, P=0.000). According to the modified MacNab criteria, the results were excellent in 32 cases, good in 9 cases, and fair in 3 cases, with an excellent and good rate of 93.2%.

Conclusion

Percutaneous endoscopic transforaminal bilateral decompression for treating severe central lumbar spinal stenosis has the advantages of less trauma, adequate decompression, and rapid recovery. The short-term effectiveness is good.

Full-Endoscopic Lumbar Foraminoplasty for Symptomatic Cement Leakage with Exiting Nerve Root Impingement

BACKGROUND

Foraminal stenosis, a common disorder occurring in elderly patients, is often caused by narrowing of the foramen, resulting in the confinement of neural structures by the tissue and vertebrae. Full-endoscopic lumbar foraminoplasty (FELF) is an effective treatment option for patients with foraminal stenosis. However, to the best of our knowledge, no previous study has reported the treatment of symptomatic cement leakage. We report a case of symptomatic cement leakage treated with FELF with the patient under local anesthesia.

CASE DESCRIPTION

An 85-year-old woman was admitted to our spine unit because of lower back pain. The patient had presented with lower back pain and new-onset left thigh pain after vertebroplasty performed 3 months previously. The patient was not able to walk and was bedridden. To overcome this problem, T12 percutaneous vertebroplasty and left transforaminal L3-L4 foraminoplasty was performed with the patient under local anesthesia. After surgery, the patient was able to walk and was discharged 4 days postoperatively.

CONCLUSION

The present report has shown that FELF can successfully remove symptomatic cement leakage, resulting in pain relief.

[Percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for lumbar spinal stenosis]

OBJECTIVE

To design the surgical strategy of percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral lumbar spinal stenosis (LSS) and to evaluate the effectiveness.

METHODS

The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral LSS was designed according to the pathological features of LSS. The technique was used to treat 42 patients with LSS between January 2016 and January 2018. There were 18 males and 24 females with an average age of 61.7 years (range, 46-81 years). The duration of symptoms was 1-20 years, with an average of 9.7 years. The surgical segment at L 4, 5 were 27 cases, at L 5, S 1 were 15 cases. The operation time and perioperative complications were recorded. Lumbar X-ray, CT, and MRI examinations were performed at 1 week, 3 months, and 1 year after operation. Visual analogue scale (VAS) score was used to evaluate the low back pain and leg pain, Oswestry disability index (ODI) was used to evaluate the lumbar function, and single continuous walking distance (SCWD) was used to evaluate lower extremity nerve function. The clinical efficacy was evaluated by MacNab criteria at 1 year after operation.

RESULTS

All patients underwent surgery successfully. The operation time was 68-141 minutes with an average of 98.2 minutes. All 42 patients were followed up 12-24 months with an average of 18.8 months. There were 2 cases of dural tears during operation, and 1 case of transient dysfunction of the lower limbs of the decompression channel after operation. All of them were cured after corresponding treatment. No serious complications such as death, major bleeding, or irreversible nerve injury occurred during follow-up. No segmental instability was found according to postoperative lumbar hyperextension and flexion X-ray films, and postoperative CT and MRI imaging showed that the stenotic lumbar spinal canal was significantly enlarged, and the compression of the nerve root was sufficient. The VAS score of low back pain and leg pain, ODI score, and SCWD at each time point after operation were significantly improved when compared with those before operation ( P<0.05); the indexes were significantly improved over time after operation, and the differences were significantly ( P<0.05). The clinical efficacy was evaluated by MacNab standard at 1 year after operation, and the results were excellent in 18 cases, good in 20 cases, fair in 3 cases, and poor in 1 case. The excellent and good rate was 90.5%.

CONCLUSION

The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for LSS is a safe and effective procedure. A well-designed surgical strategy and mastery of its technical points are important guarantees for successful operation and satisfactory results.

[Reconsideration of lumbar spinal stenosis]

People's understanding of lumbar spinal stenosis has become more and more comprehensive and reasonable, however, there are still many controversies about the concepts of "central lumbar canal" and "lateral lumbar spinal canal", and there is no unified standard at present. In this paper, we redefine and differentiate the two concepts. We believe that some kinds of central canal stenosis caused by bilateral recess stenosis can be completely solved by bilateral percutaneous endoscopic transforaminal discectomy. At the same time, the concept of "lumbar lateral recess" is ambiguous. We redefine it as "lateral lumbar spinal canal" and propose "West China Hospital classification" to guide surgical decision-making, which has been widely recognized and applied.

Endoscopic Ventral Decompression for Spinal Stenosis with Degenerative Spondylolisthesis by Partially Removing Posterosuperior Margin Underneath the Slipping Vertebral Body: Technical Note and Outcome Evaluation

BACKGROUND

Decompression alone is a treatment option in patients with lumbar spinal stenosis (LSS) and degenerative lumbar spondylolisthesis (DLS). This study aims to describe the procedure of percutaneous transforaminal endoscopic ventral decompression technique and to demonstrate the clinical outcomes.

METHODS

Two years of retrospective data were collected from 26 patients with predominant unilateral leg pain caused by LSS and low-grade DLS (Meyerding grades I and Ⅱ). All patients underwent endoscopic ventral decompression by removing the posterosuperior margin underneath the slipping vertebral body, combined with dorsal decompression without excessive resection of facet joints. The surgical outcomes were assessed using the visual analog scale (VAS), Oswestry Disability Index (ODI), modified MacNab criteria, and walking distance improvement evaluation.

RESULTS

The mean age of the 18 women and 8 men was 69.2 years. The mean preoperative ODI and VAS of the leg and the back scores were 64.7 ± 8.1, 7.0 ± 1.4, and 3.0 ± 1.2, respectively. All mean scores improved postoperatively to 31.4 ± 5.6, 2.4 ± 1.1, and 1.7 ± 1.1 at the final follow-up. In 88.5% of cases, patients' estimated walking distance improved. The outcomes of the modified MacNab criteria showed that 81.3% of patients obtained good-to-excellent rate. There were no statistically significant differences between the percent slip of spondylolisthesis before surgery and at the end of follow-up.

CONCLUSIONS

Based on the initial short-term follow-up results, transforaminal endoscopic ventral decompression by partially removing the posterosuperior margin underneath the slipping vertebral body, combined with dorsal decompression, might be an efficient alternative treatment for leg dominant symptoms in patients with LSS and low-grade DLS.