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Navigated Transtubular Extraforaminal Decompression of the L5 Nerve Root at the Lumbosacral Junction: Clinical Data, Radiographic Features, and Outcome Analysis.

Stavrinou P, Härtl R, Krischek B, Kabbasch C, Mpotsaris A, Goldbrunner R - Biomed Res Int (2016)

Bottom Line: There was a significant improvement from preoperative to postoperative NRS with the results being sustainable at follow-up.ODI was also significantly improved after surgery.Conclusions.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University Hospital of Cologne, 50937 Cologne, Germany.

ABSTRACT
Purpose. Extraforaminal decompression of the L5 nerve root remains a challenge due to anatomic constraints, severe level-degeneration, and variable anatomy. The purpose of this study is to introduce the use of navigation for transmuscular transtubular decompression at the L5/S1 level and report on radiological features and clinical outcome. Methods. Ten patients who underwent a navigation-assisted extraforaminal decompression of the L5 nerve root were retrospectively analyzed. Results. Six patients had an extraforaminal herniated disc and four had a foraminal stenosis. The distance between the L5 transverse process and the para-articular notch of the sacrum was 12.1 mm in patients with a herniated disc and 8.1 mm in those with a foraminal stenosis. One patient had an early recurrence and another developed dysesthesia that resolved after 3 months. There was a significant improvement from preoperative to postoperative NRS with the results being sustainable at follow-up. ODI was also significantly improved after surgery. According to the Macnab grading scale, excellent or good outcomes were obtained in 8 patients and fair ones in 2. Conclusions. The navigated transmuscular transtubular approach to the lumbosacral junction allows for optimal placement of the retractor and excellent orientation particularly for foraminal stenosis or in cases of complex anatomy.

No MeSH data available.


Related in: MedlinePlus

Extraforaminal stenosis at the lumbosacral junction. The degeneration of the lower lumbar spine leads to collapsing of the L5-S1 segment, contact between the sacrum and the L5-transverse process, and a very narrow operating window on the symptomatic side (left) that requires significant bone removal (patient number 3).
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fig4: Extraforaminal stenosis at the lumbosacral junction. The degeneration of the lower lumbar spine leads to collapsing of the L5-S1 segment, contact between the sacrum and the L5-transverse process, and a very narrow operating window on the symptomatic side (left) that requires significant bone removal (patient number 3).

Mentions: The literature suggests very good clinical results with extraforaminal approaches—both microscopic and endoscopic—as long as there is adequate decompression of the affected nerve. The challenge is achieving an adequate decompression while at the same time avoiding unnecessary bone and soft tissue trauma all through a very narrow and deep corridor and a highly variable anatomy. The endoscope is certainly a valuable tool in experienced hands, but the learning curve is extensive. While most surgeons are familiar with the use of the microscope, operating through a tubular retractor limits the surgical exposure and deprives the surgeon of the familiar landmarks. Additionally, the rarity of the extraforaminal disc herniation and stenosis of the L5-S1 level makes it rather hard to accumulate experience, particularly in low-volume departments. The use of navigation helps circumvent that problem. It allows an optimal placement of the tubular retractor, even in the absence of any visual anatomical landmarks and an estimation of the distance to the structures of interest. Another significant advantage is the assessment of necessary bone removal in cases of foraminal stenosis or challenging anatomy: the inability to decompress the intraforaminal area has been considered one of the limitations of the approach (Figure 4). Navigation allows for a precise assessment of the necessary degree of facet resection, thus minimizing the risk for residual stenosis or instability.


Navigated Transtubular Extraforaminal Decompression of the L5 Nerve Root at the Lumbosacral Junction: Clinical Data, Radiographic Features, and Outcome Analysis.

Stavrinou P, Härtl R, Krischek B, Kabbasch C, Mpotsaris A, Goldbrunner R - Biomed Res Int (2016)

Extraforaminal stenosis at the lumbosacral junction. The degeneration of the lower lumbar spine leads to collapsing of the L5-S1 segment, contact between the sacrum and the L5-transverse process, and a very narrow operating window on the symptomatic side (left) that requires significant bone removal (patient number 3).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4834392&req=5

fig4: Extraforaminal stenosis at the lumbosacral junction. The degeneration of the lower lumbar spine leads to collapsing of the L5-S1 segment, contact between the sacrum and the L5-transverse process, and a very narrow operating window on the symptomatic side (left) that requires significant bone removal (patient number 3).
Mentions: The literature suggests very good clinical results with extraforaminal approaches—both microscopic and endoscopic—as long as there is adequate decompression of the affected nerve. The challenge is achieving an adequate decompression while at the same time avoiding unnecessary bone and soft tissue trauma all through a very narrow and deep corridor and a highly variable anatomy. The endoscope is certainly a valuable tool in experienced hands, but the learning curve is extensive. While most surgeons are familiar with the use of the microscope, operating through a tubular retractor limits the surgical exposure and deprives the surgeon of the familiar landmarks. Additionally, the rarity of the extraforaminal disc herniation and stenosis of the L5-S1 level makes it rather hard to accumulate experience, particularly in low-volume departments. The use of navigation helps circumvent that problem. It allows an optimal placement of the tubular retractor, even in the absence of any visual anatomical landmarks and an estimation of the distance to the structures of interest. Another significant advantage is the assessment of necessary bone removal in cases of foraminal stenosis or challenging anatomy: the inability to decompress the intraforaminal area has been considered one of the limitations of the approach (Figure 4). Navigation allows for a precise assessment of the necessary degree of facet resection, thus minimizing the risk for residual stenosis or instability.

Bottom Line: There was a significant improvement from preoperative to postoperative NRS with the results being sustainable at follow-up.ODI was also significantly improved after surgery.Conclusions.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University Hospital of Cologne, 50937 Cologne, Germany.

ABSTRACT
Purpose. Extraforaminal decompression of the L5 nerve root remains a challenge due to anatomic constraints, severe level-degeneration, and variable anatomy. The purpose of this study is to introduce the use of navigation for transmuscular transtubular decompression at the L5/S1 level and report on radiological features and clinical outcome. Methods. Ten patients who underwent a navigation-assisted extraforaminal decompression of the L5 nerve root were retrospectively analyzed. Results. Six patients had an extraforaminal herniated disc and four had a foraminal stenosis. The distance between the L5 transverse process and the para-articular notch of the sacrum was 12.1 mm in patients with a herniated disc and 8.1 mm in those with a foraminal stenosis. One patient had an early recurrence and another developed dysesthesia that resolved after 3 months. There was a significant improvement from preoperative to postoperative NRS with the results being sustainable at follow-up. ODI was also significantly improved after surgery. According to the Macnab grading scale, excellent or good outcomes were obtained in 8 patients and fair ones in 2. Conclusions. The navigated transmuscular transtubular approach to the lumbosacral junction allows for optimal placement of the retractor and excellent orientation particularly for foraminal stenosis or in cases of complex anatomy.

No MeSH data available.


Related in: MedlinePlus