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Akihito Minamide, Munehito Yoshida, Andrew K. Simpson, Hiroshi Yamada, Hiroshi Hashizume, Yukihiro Nakagawa, Hiroshi Iwasaki, Shunji Tsutsui, Motohiro Okada, Masanari Takami and Shin-ichi Nakao

OBJECTIVE

The goal of this study was to characterize the long-term clinical and radiological results of articular segmental decompression surgery using endoscopy (cervical microendoscopic laminotomy [CMEL]) for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP).

METHODS

Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n = 78) underwent CMEL or ELAP. All patients were followed postoperatively for more than 5 years. The preoperative and 5-year follow-up evaluations included neurological assessment (Japanese Orthopaedic Association [JOA] score), JOA recovery rates, axial neck pain (using a visual analog scale), the SF-36, and cervical sagittal alignment (C2–7 subaxial cervical angle).

RESULTS

Sixty-one patients were included for analysis, 31 in the CMEL group and 30 in the ELAP group. The mean preoperative JOA score was 10.1 points in the CMEL group and 10.9 points in the ELAP group (p > 0.05). The JOA recovery rates were similar, 57.6% in the CMEL group and 55.4% in the ELAP group (p > 0.05). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (p < 0.01). At the 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.6° gain in lordosis (versus 1.2° loss of lordosis in the ELAP group [p < 0.05]) and lower incidence of postoperative kyphosis.

CONCLUSIONS

CMEL is a novel, less invasive technique that allows for multilevel posterior cervical decompression for the treatment of CSM. This 5-year follow-up data demonstrates that after undergoing CMEL, patients have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional ELAP counterparts.

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Akihito Minamide, Munehito Yoshida, Hiroshi Yamada, Yukihiro Nakagawa, Masaki Kawai, Kazuhiro Maio, Hiroshi Hashizume, Hiroshi Iwasaki and Shunji Tsutsui

Object

The authors undertook this study to document the clinical outcomes of microendoscopic laminotomy, a minimally invasive decompressive surgical technique using spinal endoscopy for lumbar decompression, in patients with lumbar spinal stenosis (LSS).

Methods

A total of 366 patients were enrolled in the study and underwent microendoscopic laminotomy between 2007 and 2010. Indications for surgery were single- or double-level LSS, persistent neurological symptoms, and failure of conservative treatment. Microendoscopy provided wide visualization through oblique lenses and allowed bilateral decompression via a unilateral approach, through partial resection of the base of the spinous process, thereby preserving the supraspinous and interspinous ligaments and contralateral musculature. Clinical symptoms and signs of low-back pain were evaluated prior to and following surgical intervention by applying the Japanese Orthopaedic Association (JOA) scoring system, Roland-Morris Disability Questionnaire (RMDQ), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and 36-Item Short Form Health Survey (SF-36). These items were evaluated preoperatively and 2 years postoperatively.

Results

Effective circumferential decompression was achieved in all patients. The 2-year follow-up evaluation was completed for 310 patients (148 men and 162 women; mean age 68.7 years). The average recovery rate based on the JOA score was 61.3%. The overall results were excellent in 34.9% of the patients, good in 34.9%, fair in 21.7%, and poor in 8.5%. The mean RMDQ score significantly improved from 11.3 to 4.8 (p < 0.001). In all categories of both JOABPEQ and SF-36, scores at 2 years' follow-up were significantly higher than those obtained before surgery (p < 0.001). Twelve surgery-related complications were identified: dural tear (6 cases [1.9%]), wrong-level operation (1 [0.3%]), transient neuralgia (4 [1.3%]), and infection (1 [0.3%]). All patients recovered, and there were no serious postoperative complications.

Conclusions

Microendoscopic laminotomy is a safe and very effective minimally invasive surgical technique for the treatment of degenerative LSS.

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Shizumasa Murata, Akihito Minamide, Hiroshi Iwasaki, Yukihiro Nakagawa, Hiroshi Hashizume, Yasutsugu Yukawa, Shunji Tsutsui, Masanari Takami, Motohiro Okada, Keiji Nagata, Munehito Yoshida, Andrew J. Schoenfeld, Andrew K. Simpson and Hiroshi Yamada

OBJECTIVE

Persistent lumbar foraminal stenosis (LFS) is one of the most common reasons for poor postoperative outcomes and is a major contributor to “failed back surgery syndrome.” The authors describe a new surgical strategy for LFS based on anatomical considerations using 3D image fusion with MRI/CT analysis.

METHODS

A retrospective review was conducted on 78 consecutive patients surgically treated for LFS at the lumbosacral junction (2013–2017). The location and extent of stenosis, including the narrowest site and associated pathology (bone or soft tissue), were measured using 3D image fusion with MRI/CT. Stenosis was defined as medial intervertebral foraminal (MF; inner edge to pedicle center), lateral intervertebral foraminal (LF; pedicle center to outer edge), or extraforaminal (EF; outside the pedicle). Lumbar (low-back pain, leg pain) and patient satisfaction visual analog scale (VAS) scores and Japanese Orthopaedic Association (JOA) scores were evaluated. Surgical outcome was evaluated 2 years postoperatively.

RESULTS

Most instances of stenosis existed outside the pedicle’s center (94%), including LF (58%), EF (36%), and MF (6%). In all MF cases, stenosis resulted from soft-tissue structures. The narrowest stenosis sites were localized around the pedicle’s outer border. The areas for sufficient nerve decompression were extended in MF+LF (10%), MF+LF+EF (14%), LF+EF (39%), LF (11%), and EF (26%). No iatrogenic pars interarticularis damage occurred. The JOA score was 14.9 ± 2.6 points preoperatively and 22.4 ± 3.5 points at 2 years postoperatively. The JOA recovery rate was 56.0% ± 18.6%. The VAS score (low-back and leg pain) was significantly improved 2 years postoperatively (p < 0.01). According to patients’ self-assessment of the minimally invasive surgery, 62 (79.5%) chose “surgery met my expectations” at follow-up. Nine patients (11.5%) selected “I did not improve as much as I had hoped but I would undergo the same surgery for the same outcome.”

CONCLUSIONS

Most LFS existed outside the pedicle’s center and was rarely noted in the pars region. The main regions of stenosis were localized to the pedicle’s outer edge. Considering this anatomical distribution of LFS, the authors recommend that lateral fenestration should be the first priority for foraminal decompression. Other surgical options including foraminotomy, total facetectomy, and hemilaminectomy likely require more bone resections than LFS treatment. The microendoscopic surgery results were very good, indicating that this minimally invasive surgery was suitable for treating this disease.