Stand-alone Lateral Recess Decompression Without Discectomy in Patients Presenting With Claudicant Radicular Pain and MRI Evidence of Lumbar Disc Herniation: A Prospective Study

Transforaminal Endoscopic Ventral Stenosis Decompression in Calcified Lumbar Disc Herniation: A Long Term Outcome in 79 Patients

BACKGROUND

Calcified lumbar disc herniations (CLDH) causing calcified ventral stenosis pose a therapeutic challenge to the treating surgeon due to their neural adhesions, location, and hardness.

METHODS

This retrospective study analyzed all the cases of CLDH/calcified ventral stenosis managed by transforaminal endoscopic lumbar discectomy with a minimum follow-up of 24 months. The preoperative images were analyzed for the level, migration; and grade (Lee's migration zones), and location (Michigan State University classification). Detailed surgical technique and intraoperative parameters including the duration of surgery and complications have been recorded. The clinical parameters including visual analog scale (VAS), Oswestry disability index (ODI), length of stay in hospital, days of return to basic work, and patient satisfaction index were analyzed. Postoperatively the images were analyzed for the adequacy of decompression.

RESULTS

The mean VAS for back pain and leg pain was 4.7 ± 2.6 (0-9), and 7.45 ± 2.2 (1-10), respectively. The mean preoperative ODI was 78.2 ± 13.2 (63.2-95.6). Nineteen patients (24%) had neurological deficits preoperatively. The mean duration of surgery was 90.5 ± 15.8 (58-131) minutes. Postoperative magnetic resonance imaging revealed adequate decompression in 97.5% (n = 77). The mean duration of hospital stay was 1.05 ± 0.22 (1-2) days, and the postoperative back and leg pain VAS was 1.14 ± 1.2 (0-3) (P < 0.05) and 1.7 ± 0.5 (0-6) (P < 0.05), respectively. The ODI at final follow-up was 6.5 ± 3.7 (2.2-18) (P < 0.05). Neurological recovery occurred in 17 (89.5%) patients and they returned to basic work/jobs in 19.5 ± 3.3 (14-26) days. The mean patient satisfaction index was 1.18 ± 0.47 (1-2) at a mean follow-up of 5.52 ± 2.91 (2-12.75) years.

CONCLUSIONS

Transforaminal endoscopic lumbar discectomy is a complete, safe, and efficacious procedure in patients with CLDH with earlier recovery considering the surgery is performed with the patient being awake.

Contralateral approach using microscope and tubular retractor system for ipsilateral decompression of lumbar degenerative lateral recess stenosis associated with narrow spinal canal

Objective

To summarize the clinical effect of a single-center retrospective analysis of the contralateral approach with a microscope and tubular retractor system for ipsilateral decompression in patients with lumbar lateral recess stenosis and a narrow spinal canal.

Methods

A total of 25 patients who underwent ipsilateral decompression surgery via a contralateral approach with microscope and tubular retractor system, performed by one surgeon at a single center were retrospectively examined. The width of the lamina fenestration was compared with the preoperative distance from the root of the spinous process to the dorsal articular facet, the bilateral articular facet change in the suprapedicle notch section on CT scan, and with the changes in transverse and sagittal diameters of the canal area on MRI. Clinical efficacy was assessed using the Japanese Orthopedic Association (JOA), Visual Analog Scale (VAS), and Oswestry Disability Index (ODI) scores.

Results

In total, 25 patients were treated and the mean intraoperative time was 82.04 ± 12.48 min. There was no nerve injury, cerebrospinal fluid leakage, and infection complications. The postoperative CT revealed that the width of the contralateral laminar fenestration was less than the distance from the root of the spinous process to the dorsal articular facet. The residual widths of the ipsilateral articular facet and contralateral articular facet were greater than 2/3 of the preoperative articular facet width. The transverse and sagittal diameter of canal were significantly increased. The mean follow-up period was 12-16 months, and no recurrence or reoperation incidence were found at the last follow-up. When compared to pre-surgery, the ODI, VAS, and JOA scores were significantly improved after surgery (p < 0.05).

Conclusion

Based on our single-center retrospective observation of 25 cases and combined with previous literature, the contralateral approach with a microscope and tubular retractor system for ipsilateral decompression in patients with lumbar lateral recess stenosis and a narrow spinal canal can reduce damage to the articular processes, and probably more conducive to the postoperative stability of the lumbar spine. This was a single center retrospective analysis with a small sample size and lacked randomized controlled trials (RCTs). However, larger-scale, multicenter RTCs are required for additional validation.

Risk Factors Involved in the Early and Medium-Term Poor Outcomes of Percutaneous Endoscopic Transforaminal Discectomy: A Single-Center Experience

Objective

To investigate the risk factors involved in the early and medium-term poor outcomes of percutaneous endoscopic transforaminal discectomy (PETD) treatment of lumbar disc herniation (LDH) at the L4-5 level.

Methods

Between January 2015 and May 2020, we recruited 148 LDH patients at the L4-5 level who underwent PETD surgery. The patients were divided into Groups A and B, according to the surgical outcomes. Good and excellent outcomes were categorized into Group A, and generally good and poor outcomes were categorized into Group B. Clinical parameters (age, gender, symptom duration, hospital stay, operation time, blood loss, straight-leg raising (SLR), visual analog scale (VAS), Oswestry Disability Index (ODI) score and modified MacNab criteria) and radiologic parameters (foraminal height (FH), intervertebral height index (IHI), intervertebral angle (IVA), sagittal range of motion (sROM), and lumbar lordosis (LL)) were collected and analyzed using univariate and multiple logistic regression analyses.

Results

At the 6-month follow-up post operation, univariate analysis revealed that the symptom duration, SLR, IHI, and sROM were strongly associated with poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes. At the 2-year follow-up post operation, univariate analysis suggested that advanced age, prolonged symptom duration, large preoperative VAS score, small FH, small IHI, and large sROM were potential risk factors for poor outcomes. However, multiple logistic regression analysis demonstrated that prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes.

Conclusion

Our study demonstrated that prolonged symptom duration, large SLR angel, and large sROM were independent risk factors for poor outcomes immediately following PETD at the L4-5 level. However, prolonged symptom duration, small IHI, and large sROM were independent risk factors for poor outcomes at medium-term post PETD at the L4-5 level.

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.

Sufficient Lumbar Lateral Recess Decompression Acquired by Undercutting "Superior Articular Process Neck" Plus Intervertebral Disk Annuloplasty in Percutaneous Transforaminal Endoscopic Surgery

Background

Percutaneous transforaminal endoscopic surgery has been used as a surgical measure for lumbar lateral recess stenosis. However, the necessary decompressive range has never been clearly documented in detail. Here, we discuss the effectiveness of a percutaneous transforaminal endoscopic procedure with clearly defined decompressive range.

Material/Methods

The relevant data were retrospectively collected from a series of degenerative lateral recess stenosis patients who acquired a prospectively designed percutaneous transforaminal endoscopic procedure in our department. The decompressive procedure mainly included undercutting of superior articular process and intervertebral disk annuloplasty. Leg pain and back pain was evaluated using visual analogue scale (VAS). The functional status was assessed using Oswestry disability index (ODI). The clinical results were also evaluated using MacNab criteria.

Results

From May 2014 to October 2018, a total of 33 patients who met our inclusion criteria were included for analysis. There were no perioperative complications. Leg pain VAS decreased from preoperative score of 6.18±2.38 to final follow-up score of 0.45±1.00 (P<0.01). Back pain VAS decreased from preoperative score of 1.88±2.19 to final follow-up score of 0.64±1.02 (P<0.01). ODI (%) decreased from preoperative score of 47.86±18.15 to final follow-up score of 6.29±6.75 (P<0.01). At the final follow-up, the results of MacNab criteria were excellent in 18 cases (54.55%), good in 14 cases (42.42%), fair in 1 case (3.03%) and poor in 0 cases. None of the patients complained of recurrence of the symptoms during follow-up.

Conclusions

Undercutting of “superior articular process neck” plus intervertebral disk annuloplasty is sufficient for lumbar lateral recess decompression in a transforaminal approach.

Which clinical and radiological variables could predict clinical outcomes of percutaneous endoscopic lumbar discectomy for treatment of patients with lumbosacral disc herniation?

BACKGROUND CONTEXT

Percutaneous endoscopic lumbar discectomy (PELD) is one of minimally invasive techniques to treat patients with low back and radiating pain resulting from lumbosacral disc herniation (LDH).

PURPOSE

The purpose of this study is to evaluate the clinical efficacy of PELD to treat patients with low back and radicular pain due to LDH and to investigate which clinical and radiological variables have the ability to predict clinical outcome after PELD.

STUDY DESIGN/SETTING

This is a retrospective study design carried out at a spine hospital.

PATIENT SAMPLE

The sample comprised 75 patients who had undergone PELD for treatment of low back and radiating leg pain resulting from LDH and who could be followed up for at least 12 months.

OUTCOMES MEASURES

Clinical outcomes were assessed using numeric rating scale for back and radiating leg pain (NRS back and leg), Oswestry Disability Index (ODI), and modified MacNab criteria at 1 month (short-term follow-up) and at least 12 months (long-term follow-up) after PELD.

METHODS

The patients were divided into successful and unsuccessful outcome groups according to improvement of NRS back, NRS leg, and ODI (%) at long-term follow-up period. We compared the various clinical and radiological variables between the two groups to identify which variables could be the prognostic factors of clinical outcomes of PELD. This analysis was performed in terms of whole population, the subgroup of dominant back pain, and the subgroup of dominant leg pain, respectively.

RESULTS

Significant improvements were observed in NRS back, NRS leg, ODI (%), and modified MacNab criteria at short-term and long-term follow-up after PELD. Positive straight leg raising (SLR) was significantly related to successful outcome as to NRS leg and ODI (%), and longer pain duration also showed significant relationship with unsuccessful outcomes as to NRS leg in whole population. Positive SLR had significant relationship with successful NRS leg as well as successful ODI (%) in the subgroup of dominant leg pain.

CONCLUSIONS

PELD was an effective treatment in patients with back and leg pain due to LDH. Positive SLR had the predictive ability to successful reduction of radiating leg pain and successful functional improvement. Longer pain duration was also related to unsuccessful reduction of radiating leg pain.