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"Outside-in" technique, clinical results, and indications with transforaminal lumbar endoscopic surgery: a retrospective study on 220 patients on applied radiographic classification of foraminal spinal stenosis.

Lewandrowski KU - Int J Spine Surg (2014)

Bottom Line: According to the Macnab criteria, excellent and good results were obtained in 85% (186/220) of patients with monoradiculopathy.The mean VAS score decreased from 7.5 ± 1.5 preoperatively to 2.8 ± 1.9 at the final follow-up (P < 0.01).Less favorable outcomes were observed in patients with concomitant contained disc herniations when compared to extruded disc herniations (P < 0.03) as well in patients older than 50 years of age (P < 0.021).

View Article: PubMed Central - PubMed

Affiliation: Center for Advanced Spinal Surgery of Southern Arizona, Tucson, AZ.

ABSTRACT

Objective: To analyze and describe appropriate surgical indications for endoscopically performed transforaminal decompression with the outside-in technique with foraminoplasty in patients with lateral stenosis with and without herniated disc.

Background and significance: Endoscopic microdiscectomy is growing in popularity for the removal of lumbar disc herniations. Recent advances in surgical techniques allow for percutaneous endoscopically assisted bony decompression as well.

Materials and methods: A retrospective study of 220 consecutive patients undergoing percutaneous endoscopic transforaminal foraminoplasty and microdiscectomy at 228 levels was conducted with intent of identifying appropriate surgical indications in patients with monoradiculopathy. The mean follow up was 46 months ranging from 26 to 54 months. Preoperatively, foraminal and lateral recess stenosis was graded on preoperative MRI and CT scans by dividing the lumbar neuroforamen into three zones: a) entry zone, b) middle zone, and c) exit zone. In addition, the presence of disc herniation causing neural element compression in the lateral recess and neuroforamen was noted. Disc herniations, if present, were recorded as either extruded and contained disc herniations. Surgical outcomes were classified according to the Macnab criteria. In addition, reductions in VAS scores were assessed.

Results: According to the Macnab criteria, excellent and good results were obtained in 85% (186/220) of patients with monoradiculopathy. The mean VAS score decreased from 7.5 ± 1.5 preoperatively to 2.8 ± 1.9 at the final follow-up (P < 0.01). Concomitant extruded disc herniations and contained disc bulges were recorded in 24 and 82 patients, respectively. There were no approach-related complications. Clinical failures occurred in patients with bony stenosis in the lateral recess and entry zone of the neuroforamen. Less favorable outcomes were observed in patients with concomitant contained disc herniations when compared to extruded disc herniations (P < 0.03) as well in patients older than 50 years of age (P < 0.021).

Conclusions: Percutaneous, endoscopic decompression using outside-in technique works well in patients with monoradiculopathy due to lateral stenosis in the mid and exit zone of the neuroforamen. Decompression in the entry zone maybe inadequate using the transforaminal outside-in approach. Future studies with greater statistical power should determine as to whether pain relief was achieved via microdiscectomy or foraminoplasty.

No MeSH data available.


Related in: MedlinePlus

The chisel is advanced through the central working channel of the endoscope. A mallet may be used to advance the chisel for the foraminoplasty. Typically, a direct lateral approach to the foramen by dropping one's hand is more advantageous. The foraminoplasty can be facilitaed by chiseling in an upward diretion, then by rotating the chisel by 180 degrees followed by downward chiseling.
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Figure 0004: The chisel is advanced through the central working channel of the endoscope. A mallet may be used to advance the chisel for the foraminoplasty. Typically, a direct lateral approach to the foramen by dropping one's hand is more advantageous. The foraminoplasty can be facilitaed by chiseling in an upward diretion, then by rotating the chisel by 180 degrees followed by downward chiseling.

Mentions: For the foraminoplasty, bone from the hypertrophied superior and inferior articular process was removed with different instruments including endoscopic chisels, drills, Kerrison rongeurs, and percutaneous trephines (Figure 3, Figure 4, Figure 5, Figure 6). The foraminoplasty was facilitated by changing the trajectory of the instruments to aim for the compressive pathology identified on preoperative studies. In case of concomitant herniated disc, extruded disc material was removed using forceps and pituitary rongeurs and contained herniations were decompressed through a small annular window. Epidural bleeding was controlled with a radiofrequency probe (Ellman; Ellman International LLC, USA) under saline irrigation.


"Outside-in" technique, clinical results, and indications with transforaminal lumbar endoscopic surgery: a retrospective study on 220 patients on applied radiographic classification of foraminal spinal stenosis.

Lewandrowski KU - Int J Spine Surg (2014)

The chisel is advanced through the central working channel of the endoscope. A mallet may be used to advance the chisel for the foraminoplasty. Typically, a direct lateral approach to the foramen by dropping one's hand is more advantageous. The foraminoplasty can be facilitaed by chiseling in an upward diretion, then by rotating the chisel by 180 degrees followed by downward chiseling.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4325483&req=5

Figure 0004: The chisel is advanced through the central working channel of the endoscope. A mallet may be used to advance the chisel for the foraminoplasty. Typically, a direct lateral approach to the foramen by dropping one's hand is more advantageous. The foraminoplasty can be facilitaed by chiseling in an upward diretion, then by rotating the chisel by 180 degrees followed by downward chiseling.
Mentions: For the foraminoplasty, bone from the hypertrophied superior and inferior articular process was removed with different instruments including endoscopic chisels, drills, Kerrison rongeurs, and percutaneous trephines (Figure 3, Figure 4, Figure 5, Figure 6). The foraminoplasty was facilitated by changing the trajectory of the instruments to aim for the compressive pathology identified on preoperative studies. In case of concomitant herniated disc, extruded disc material was removed using forceps and pituitary rongeurs and contained herniations were decompressed through a small annular window. Epidural bleeding was controlled with a radiofrequency probe (Ellman; Ellman International LLC, USA) under saline irrigation.

Bottom Line: According to the Macnab criteria, excellent and good results were obtained in 85% (186/220) of patients with monoradiculopathy.The mean VAS score decreased from 7.5 ± 1.5 preoperatively to 2.8 ± 1.9 at the final follow-up (P < 0.01).Less favorable outcomes were observed in patients with concomitant contained disc herniations when compared to extruded disc herniations (P < 0.03) as well in patients older than 50 years of age (P < 0.021).

View Article: PubMed Central - PubMed

Affiliation: Center for Advanced Spinal Surgery of Southern Arizona, Tucson, AZ.

ABSTRACT

Objective: To analyze and describe appropriate surgical indications for endoscopically performed transforaminal decompression with the outside-in technique with foraminoplasty in patients with lateral stenosis with and without herniated disc.

Background and significance: Endoscopic microdiscectomy is growing in popularity for the removal of lumbar disc herniations. Recent advances in surgical techniques allow for percutaneous endoscopically assisted bony decompression as well.

Materials and methods: A retrospective study of 220 consecutive patients undergoing percutaneous endoscopic transforaminal foraminoplasty and microdiscectomy at 228 levels was conducted with intent of identifying appropriate surgical indications in patients with monoradiculopathy. The mean follow up was 46 months ranging from 26 to 54 months. Preoperatively, foraminal and lateral recess stenosis was graded on preoperative MRI and CT scans by dividing the lumbar neuroforamen into three zones: a) entry zone, b) middle zone, and c) exit zone. In addition, the presence of disc herniation causing neural element compression in the lateral recess and neuroforamen was noted. Disc herniations, if present, were recorded as either extruded and contained disc herniations. Surgical outcomes were classified according to the Macnab criteria. In addition, reductions in VAS scores were assessed.

Results: According to the Macnab criteria, excellent and good results were obtained in 85% (186/220) of patients with monoradiculopathy. The mean VAS score decreased from 7.5 ± 1.5 preoperatively to 2.8 ± 1.9 at the final follow-up (P < 0.01). Concomitant extruded disc herniations and contained disc bulges were recorded in 24 and 82 patients, respectively. There were no approach-related complications. Clinical failures occurred in patients with bony stenosis in the lateral recess and entry zone of the neuroforamen. Less favorable outcomes were observed in patients with concomitant contained disc herniations when compared to extruded disc herniations (P < 0.03) as well in patients older than 50 years of age (P < 0.021).

Conclusions: Percutaneous, endoscopic decompression using outside-in technique works well in patients with monoradiculopathy due to lateral stenosis in the mid and exit zone of the neuroforamen. Decompression in the entry zone maybe inadequate using the transforaminal outside-in approach. Future studies with greater statistical power should determine as to whether pain relief was achieved via microdiscectomy or foraminoplasty.

No MeSH data available.


Related in: MedlinePlus