The "inside out" transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature.
Bottom Line: It has moved away from decisions based on diagnostic images alone, that, while noting the image alterations, cannot explain the pain experienced by each individual as images do not always show variations in nerve supply and patho-anatomy.This has also resulted in better pre surgical planning with more specific and defined goals in mind.The "Inside out" philosophy of TFE surgery is safe and precise.
Affiliation: Prime Surgical Centre, Pune, India.
Surgical management of back and leg pain is evolving and changing due to a better understanding of the patho-anatomy well correlated with its pathophysiology. Pain is better understood with in vivo visualization and probing of the pain generators using an endoscopic access rather than just relying on symptoms diagram and image correlation. This has resulted in a shared decision making involving patient and surgeon, focused on a broader spectrum of surgical as well as non-surgical treatments, and not just masking the pain generator. It has moved away from decisions based on diagnostic images alone, that, while noting the image alterations, cannot explain the pain experienced by each individual as images do not always show variations in nerve supply and patho-anatomy. The ability to isolate and visualize "pain" generators in the foramen and treating persistent pain by visualizing inflammation and compression of nerves, serves as the basis for transforaminal endoscopic (TFE) surgery. This has also resulted in better pre surgical planning with more specific and defined goals in mind. The "Inside out" philosophy of TFE surgery is safe and precise. It provides basic access to the disc and foramen to cover a large spectrum of painful pathologies.
No MeSH data available.
Related in: MedlinePlus
Mentions: The initial change in cases of disc degeneration is an annular tear. The tear may leak and cause inflammation around nerve root or DRG. The weakened annulus may give rise to a subsequent herniation through this tear, so we must target the fragment, annular tear, and the leak from the tear. Physiologically, the inflammation gives rise to mechano-sensitization of the nerve roots and DRG, which requires removal of the embedded disc fragments in the annulus to allow that torn annulus to heal. Access is by a needle directed in a shallow trajectory to enable instruments to remove the embedded disc fragments in the tear. For visualized thermal modulation, access is then dilated by using an obturator which makes way for a working sheath that accommodates an endoscope. Thus, introduction of an endoscope without any tissue cutting is desired. The landing of instruments is in the foramen below the facet in the safe triangle as described by Kambin. Figure 4 highlights cadaver dissection showing same area accessed by open or endoscopic method. Figure 5 is Kambin's triangle. Further alterations to a more horizontal trajectory, if needed, is accomplished by foraminoplasty by facet under cutting to facilitate removal of disc fragments from the annulus. The landing point is between the medial and lateral pedicular border. In cases of hypertrophied tissue in the foramen, our efforts are directed to the roof of the foramen.
No MeSH data available.