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Takahashi K, Yadav A, Tsubakino T, Hoshikawa T, Nakagawa T, Hashimoto K, Suzuki M, Aizawa T, Tanaka Y. Radical decompression without fusion for L5 radiculopathy due to foraminal stenosis. JOURNAL OF SPINE SURGERY (HONG KONG) 2023; 9:278-287. [PMID: 37841796 PMCID: PMC10570647 DOI: 10.21037/jss-23-62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/31/2023] [Indexed: 10/17/2023]
Abstract
Background The highest incidence of lumbar foraminal stenosis (LFS) occurs in the L5-S1 segment and its anatomical features differ from those of other segments. Few previous reports have exhaustively assessed surgical outcomes after decompression surgery, limiting the materials to patients with LFS at the L5-S1 segment. We aimed to prospectively investigate instability and neurological improvement following our novel surgical technique for LFS at L5-S1, named "radical decompression" of the nerve root. Methods Patients with foraminal stenosis at L5-S1 who underwent surgery using our technique were prospectively evaluated two years postoperatively. The Japanese Orthopaedic Association (JOA) score and the JOA Back Pain Evaluation Questionnaire (JOABPEQ) were evaluated preoperatively and two years postoperatively. The following radiological parameters at L5-S1 were measured: lateral translation, sagittal translation, the difference in sagittal translation (DST) between flexion and extension, disc wedging angle, lordotic angle, the difference in lordotic angle (DLA) between flexion and extension, and disc height. Pre- and postoperative data were compared using paired t-tests. In addition, the patients were classified into a disc group (Group D) and a non-disc group (Group ND) according to whether a discectomy was performed intraoperatively. Changes in each parameter before and after surgery were compared between the groups. Results Twenty-eight patients were included in this analysis. The JOA scores improved in all patients. The mean preoperative and two-year postoperative JOA scores were 14.5±3.2 (range, 8-21) and 24.3±3.3 (range, 18-29), respectively (P<0.01). All JOABPEQ categories improved two years postoperatively (P<0.05). None of the patients underwent revision surgery. No significant changes were observed in any of the radiological parameters. No significant differences in the changes in each parameter before and after surgery were found between groups D and ND. Conclusions Our surgical technique resulted in good neurological recovery and was associated with a low risk of postoperative segmental instability, regardless of additional discectomy.
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Affiliation(s)
- Kohei Takahashi
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ajay Yadav
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Terai Hospital and Research Center, Birganj, Parsa, Nepal
| | - Takumi Tsubakino
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
| | - Takeshi Hoshikawa
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Sendai Orthopaedic Hospital, Sendai, Japan
| | - Tomowaki Nakagawa
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Sendai Orthopaedic Hospital, Sendai, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Manabu Suzuki
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhisa Tanaka
- Department of Orthopaedic Surgery, Tohoku Central Hospital, Yamagata, Japan
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Predictors of Clinical Outcome After Endoscopic Partial Facetectomy for Degenerative Lumbar Foraminal Stenosis. World Neurosurg 2019; 126:e1482-e1488. [PMID: 30905646 DOI: 10.1016/j.wneu.2019.03.126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Endoscopic partial facetectomy (EPF) is an effective option for decompressing the lumbar exiting root without causing spinal instabilities in the treatment of patients with degenerative lumbar foraminal stenosis. The aim of the present study was to identify the preoperative risk factors of poor clinical outcomes after EPF in patients with degenerative lumbar foraminal stenosis. METHODS A total of 51 consecutive patients who had undergone EPF from 2012 to 2015 were included in the present study. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry disability index (ODI), and Short-Form 36-item (SF-36) outcome questionnaires. The preoperative radiological risk factors were measured using the lumbar Cobb's angle, disc wedging angle, lumbar lordosis (LL), segmental lordosis, disc height index, presence of spondylolisthesis, and morphological changes (no change, horizontal collapse, vertical collapse) of the exiting root within the most stenotic level on preoperative magnetic resonance imaging. RESULTS The VAS, ODI, and SF-36 scores had significantly improved at the 1-month follow-up visit compared with the baseline mean values and were maintained within the 2-year follow-up period. A correlation analysis revealed significant relationships between various preoperative factors and clinical outcomes. On multiple regression analysis, the morphological change of vertical collapse significantly predicted the VAS, ODI, and SF-36 scores, and LL significantly predicted the ODI and SF-36 scores. CONCLUSIONS A morphological change in vertical collapse found on preoperative magnetic resonance imaging and decreased LL were significant predictors of poor clinical outcomes after EPF in the treatment of lumbar foraminal stenosis.
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Working Cannula-Based Endoscopic Foraminoplasty: A Technical Note. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4749560. [PMID: 30671454 PMCID: PMC6323537 DOI: 10.1155/2018/4749560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022]
Abstract
Purpose Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive disc surgery that can be performed under local anesthesia and requires only an eight-mm skin incision. For the patients with lumbar foraminal stenosis, the migrated disc is difficult to remove with a simple transforaminal approach. In such cases, the foraminoplasty techniques can be used. However, obtaining efficient foramen enlargement while minimizing radiation exposure and protecting the nerves can be challenging. Methods In this study, we propose a new technique called the Kiss-Hug maneuver. Under endoscopic viewing, we used the bevel tip of a working cannula as a bone reamer to enlarge the foramen. This allowed us to efficiently enlarge the lumbar foramen endoscopically without the redundancy and complications associated with reamers or trephines. Results Details of the four steps of the Kiss-Hug maneuver are reported along with adverse events. The advantages of this new technique include minimizing radiation exposure to both the surgeon and the patient and decreasing the overall operation time. Conclusion The endoscopic Kiss-Hug maneuver is a useful and reliable foraminoplasty technique that can enhance the efficiency of foraminoplasty while ensuring patient safety and reducing radiation exposure.
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Kim JE, Choi DJ. Unilateral Biportal Endoscopic Spinal Surgery Using a 30° Arthroscope for L5-S1 Foraminal Decompression. Clin Orthop Surg 2018; 10:508-512. [PMID: 30505421 PMCID: PMC6250961 DOI: 10.4055/cios.2018.10.4.508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 03/19/2018] [Indexed: 11/06/2022] Open
Abstract
Foraminal decompression using a minimally invasive technique to preserve facet joint stability and function without fusion reportedly improves the radicular symptoms in approximately 80% of patients and is considered one of the good surgical treatment choices for lumbar foraminal or extraforaminal stenosis. However, proper decompression was not possible because of the inability to access the foramen at the L5–S1 level due to prominence of the iliac crest. To overcome this challenge, endoscopy-based minimally invasive spine surgery has recently gained attention. Here, we report the technical skills required in unilateral extraforaminal biportal endoscopic spinal surgery using a 30° arthroscope to enable foraminal decompression at the L5–S1 level. Two 0.8-cm portals were created 2 cm lateral from the lateral border of the pedicles at the L5–S1 level. After sufficient working space was made, half of the superior articular process (SAP) in the hypertrophied facet joint was removed using a high-speed burr and a 5-mm wide osteotome, whereas the remaining inside part of the SAP was removed using a Kerrison punch and pituitary punch. The foraminal ligamentum flavum should be removed to inspect the conditions of the L5 exiting root and disc. Removing of the extruded disc could decompress the L5 root. The extraforaminal approach using a 30° arthroscope is considered a minimally invasive alternative technique for decompressing foraminal stenosis at the L5–S1 level that preserves facet stability and provides symptomatic relief.
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Affiliation(s)
- Ju-Eun Kim
- Department of Orthopedic Surgery, Andong Hospital, Andong, Korea
| | - Dae-Jung Choi
- Department of Spine Surgery, Barun Hospital, Jinju, Korea
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Buraimoh M, Ansok C, Pawloski J, Jung EK, Bartol S. Facet Sparing Foraminal Decompression Using the Flexible Shaver Foraminotomy System: Nerve Safety, Pain Relief, and Patient Satisfaction. Int J Spine Surg 2018; 12:92-97. [PMID: 30276067 DOI: 10.14444/5015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background A number of surgical options exist for decompressing lumbar foraminal stenosis. Flexible shaver foraminotomy is a recent addition to this armamentarium. While the foraminotomy device has been incorporated into clinical practice, the literature on its safety and efficacy remain limited. We aimed to evaluate nerve safety, pain relief, and patient satisfaction in a series of patients treated with the iO-Flex shaver system (Amendia, Inc., Marietta, Georgia). Methods Thirty-one consecutive patients with lumbar foraminal stenosis underwent foraminal decompression using the flexible microblade shaver system at 62 neuroforamina. The shavers were inserted into each foramen using an open hemilaminotomy and fluoroscopic guidance. Nerve mapping via mechanomyography (MMG) was used to ensure nerve safety. Perioperative charts were reviewed to find the incidence of neurologic complications and to quantify pain relief. Average office-based follow-up was 5.3 months. A 3-item questionnaire was administered to assess patient satisfaction during late follow-up, which occurred at an average of 21 months. Results No planned iO-Flex foraminotomies were aborted. Neurologic complications included transient dysesthetic pain in 1 patient (3.2%, n = 31), and transient numbness in 3 patients (9.7%, n = 31). There were no motor deficits. The composite nerve complication rate was 12.7%. Preoperative visual analog scale scores decreased from a mean of 7.1 (n = 31, standard deviation [SD] 2.0) to a mean of 3.5 (n = 30, SD 2.5). If asked to repeat their decision to do surgery, 81% of patients would redo the procedure. The rate of patient dissatisfaction was 19%. Conclusions Decompression of lumbar foramina using the flexible shaver system and MMG nerve mapping is safe and effective, although the short-term sensory complication with this technique may be higher than previously reported. Patient satisfaction with iO-Flex foraminotomy is comparable to reported satisfaction outcomes for traditional lumbar decompression. Level of Evidence 4.
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Affiliation(s)
| | - Chase Ansok
- Department of Orthopaedics, Henry Ford Hospital, Detroit, Michigan
| | - Jacob Pawloski
- Wayne State University School of Medicine, Detroit, Michigan
| | - Edward K Jung
- Department of Orthopaedics, Henry Ford Hospital, Detroit, Michigan
| | - Stephen Bartol
- Department of Orthopaedics, Henry Ford Hospital, Detroit, Michigan
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Clinical Outcome of Minimally Invasive Decompression Without Discectomy in Contained Foraminal Disc Herniation: A Single-Center Study. World Neurosurg 2018; 118:e367-e374. [PMID: 29969734 DOI: 10.1016/j.wneu.2018.06.192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Foraminal disc herniation is rare. When conservative treatment fails, it is often treated with discectomy via a paraspinal or Wiltse approach. In contained foraminal disc herniation, more symptoms arise from the foraminal compression of the exiting nerve root, including the dorsal root ganglion, than from the herniation itself. We aimed to evaluate the benefits of stand-alone decompression without discectomy for patients with contained foraminal disc herniation. METHODS This study included 17 patients with unilateral single-level foraminal disc herniation (14 women and 3 men; mean age, 62.8 ± 14.6 years, range, 37-86 years). Disc herniation was confirmed as contained by preoperative magnetic resonance imaging and/or computed tomography and by intraoperative exploration. All patients underwent thorough decompression without discectomy, via a paraspinal approach. Pain was evaluated preoperatively and at 3 and 12 months postoperatively using a visual analog scale (VAS). The Oswestry Disability Index (ODI) and Macnab criteria were used to evaluate final outcomes. RESULTS The most commonly affected level was L5-S1. All 17 patients showed significant improvements in VAS and ODI scores at 3 and 12 months postoperatively. According to the Macnab criteria, outcome results were excellent in 13 patients and good in 4. The mean duration of follow-up was 18.4 ± 2.4 months, with no recurrences or lumbar instability at the final follow-up. CONCLUSIONS Stand-alone decompression without discectomy is an effective method for relieving symptoms and preserving the disc in contained foraminal disc herniation. A minimally invasive approach with thorough decompression techniques yields good results.
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Biportal Endoscopic Spine Surgery for Various Foraminal Lesions at the Lumbosacral Lesion. Asian Spine J 2018; 12:569-573. [PMID: 29879787 PMCID: PMC6002165 DOI: 10.4184/asj.2018.12.3.569] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/28/2017] [Accepted: 10/17/2017] [Indexed: 11/08/2022] Open
Abstract
The stenosing foramen of L5-S1 by several degenerative diseases is one of the challenging areas on surgical approaching because of the deeper depth and steep slope in the lumbosacral junction. The floating view using unilateral biportal endoscopic spine surgery rather than docking into the Kambin's zone can make the foraminal structures seen panoramically and permit dynamic handling of various instruments without destroying the facet joint and causing iatrogenic instability. Fine discrimination of structural margins in helps of the higher magnification and gentle manipulation of neural structures just as in open spine surgery could be guaranteed using floating technique from the target structures. Selective decompression with preserving innocent structures including facet joints could relieve foraminal lesions at the L5-S1 and decrease the necessity of fusion surgery caused by wider decompression and iatrogenic instability.
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Ahn JS, Lee HJ, Choi DJ, Lee KY, Hwang SJ. Extraforaminal approach of biportal endoscopic spinal surgery: a new endoscopic technique for transforaminal decompression and discectomy. J Neurosurg Spine 2018; 28:492-498. [DOI: 10.3171/2017.8.spine17771] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study was performed to describe the extraforaminal approach of biportal endoscopic spinal surgery (BESS) as a new endoscopic technique for transforaminal decompression and discectomy and to demonstrate the clinical outcomes of this new procedure for the first time. Twenty-one patients (27 segments) who underwent the extraforaminal approach of BESS between March 2015 and April 2016 were enrolled according to the inclusion and exclusion criteria. The operative time (minutes/level) and complications after the procedure were recorded. The visual analog scale (VAS) score was checked to assess the degree of radicular leg pain preoperatively and at the time of the last follow-up. The modified Macnab criteria were used to examine the clinical outcomes at the time of the last follow-up. The mean duration of the follow-up period was 14.8 months (minimum duration 12 months). The mean operative time was 96.7 minutes for one level. The mean VAS score for radicular leg pain dropped from a preoperative score of 7.5 ± 0.9 to a final follow-up score of 2.5 ± 1.2 (p < 0.001). The final outcome according to the modified Macnab criteria was excellent in 5 patients (23.8%), good in 12 (57.2%), fair in 4 (19.0%), and poor in 0. Therefore, excellent or good results (a satisfied outcome) were obtained in 80.9% of the patients. Complications were limited to one dural tear (4.8%). The authors found that the extraforaminal approach of BESS was a feasible and advantageous endoscopic technique for the treatment of foraminal lesions, including stenosis and disc herniation. They suggest that this technique represents a useful, alternative, minimally invasive method that can be used to treat lumbar foraminal stenosis and disc herniation.
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Affiliation(s)
- Jae-Sung Ahn
- 1Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon; and
| | - Ho-Jin Lee
- 1Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon; and
| | - Dae-Jung Choi
- 2Spine Center, Department of Orthopaedic Surgery, Barun Hospital, Jin-ju, South Korea
| | - Ki-young Lee
- 1Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon; and
| | - Sung-jin Hwang
- 1Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon; and
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Clinical and radiological outcomes of endoscopic partial facetectomy for degenerative lumbar foraminal stenosis. Acta Neurochir (Wien) 2017; 159:1129-1135. [PMID: 28434048 DOI: 10.1007/s00701-017-3186-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several different techniques exist to treat degenerative lumbar foraminal stenosis. Failure to adequately decompress the lumbar foramen may lead to failed back surgery syndrome. However, wide decompression often causes spinal instabilities or may require an additional fusion surgery. The aim of this study was to report the outcomes of endoscopic partial facetectomy (EPF) performed on patients with degenerative lumbar foraminal stenosis. METHODS Between 2012 and 2014, 25 consecutive patients (12 women and 13 men) who underwent EPF were included in the study. The patients were assessed before surgery and followed-up regularly during outpatient visits (preoperatively and 1, 3, 6, 12, and 24 months postoperatively). The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) outcome questionnaire. The radiological outcome was measured using the lumbar Cobb angle, disc wedging angle, lumbar lordosis (LL), slip percentage, and disc height index (DHI) in plain standing radiographs. RESULTS The VAS, ODI, and SF-36 scores significantly improved at 1 month of follow-up compared with the baseline mean values and were maintained within the 2-year follow-up period. There was no radiologic progression in the lumbar Cobb's angle, disc wedging angle, LL, slip percentage, and DHI between preoperatively and 2 years postoperatively. In addition, the EPF with discectomy group and the EPF group were not significantly different in terms of clinical and radiological outcomes. CONCLUSIONS EPF is an effective option in decompressing the lumbar exiting nerve root without causing spinal instabilities for the treatment of patients with lumbar foraminal stenosis.
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