Endoscope-assisted spinal decompression surgery for lumbar spinal stenosis

Technical note

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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.

Abbreviations used in this paper:JOA = Japanese Orthopaedic Association; JOABPEQ = JOA Back Pain Evaluation Questionnaire; LSS = lumbar spinal stenosis; RMDQ = Roland-Morris Disability Questionnaire; SF-36 = 36-Item Short Form Health Survey; TLIF = transforaminal lumbar interbody fusion.

Article Information

Address correspondence to: Akihito Minamide, M.D., Ph.D., Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8510, Japan. email: minamide@wakayama-med.ac.jp.

Please include this information when citing this paper: published online October 4, 2013; DOI: 10.3171/2013.8.SPINE13125.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A–C: Photographs of the high-speed drill with a long curved endoscopic bit (A), curved Kerrison rongeurs (B), and curved ultrasonic aspirator (C) used to undercut the facet joint. D and E: The laminotomy is performed by using a long curved high-speed drill (D). After sufficient drilling, endoscopic Kerrison rongeurs are used for further lamina removal (E). Copyright Munehito Yoshida (panels D and E). Published with permission.

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    The base of the spinous process (black shadow) is drilled to obtain access to the contralateral surgical field.

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    The scope is rotated to a lateral position to make use of its 25° viewing angle. An excellent viewing angle of 60°–75° is usually obtained, with good contralateral visualization. The view area is beyond the tubular retractor. Copyright Munehito Yoshida. Published with permission.

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    Photograph obtained during microendoscopic laminotomy. The drilling is carried out with one hand. To protect the surgical site against mechanical vibration, the drill is held by the thumb and index and middle fingers; the middle or ring finger is placed on the tubular retractor; and the little finger is positioned against the skin.

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    Intraoperative endoscopic photographs obtained during microendoscopic laminotomy. It is possible to confirm the interlaminar space by drilling a part of the lamina and medial facet complex (A). The contralateral surgical field can be accessed by partially resecting the base of the spinous process. A trumpet facetectomy is achieved by use of curved instruments (high-speed drill or Kerrison rongeurs) (B). When the undercut of the attachment of the ligamentum flavum is completed, the ligament itself floats. The flavum is split along the midline and floats like open wings (C). After identifying the plane between the ligamentum flavum and the underlying dura, the hypertrophied ligament is gently removed (D). Dural pulsation is observed on removing the ligamentum flavum. After identifying the spinal nerve roots, the lateral recesses are bilaterally decompressed (E). The adequacy of decompression is determined by observing pulsation of the dural sac and probing the traversing nerve roots to ensure their mobility (F). In all panels, left is cranial and right is caudal.

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    The endoscopic surgery allows good visualization of the lateral recesses and foramina. Copyright Munehito Yoshida. Published with permission.

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    Graph showing improvement in JOABPEQ scores. In 5 categories (low-back pain, lumbar function, walking ability, social life function, and mental health) the 2-year follow-up scores were significantly higher than the preoperative scores. *p < 0.001.

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    Graph showing improvement in SF-36 scores. The scores on 8 subscales (physical functioning [PF], role physical [RP], bodily pain [BP], social functioning [SF], general health perceptions [GH], vitality [VT], role emotional [RE], and mental health [MH]) were significantly higher at 2-years' follow-up than before surgery. *p < 0.001.

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    Images obtained in a 74-year-old female patient with degenerative lumbar spondylolisthesis at L4–5 who suffered from low-back and leg pain. She experienced intermittent claudication after walking for 200 m. A: Preoperative flexion-extension radiographs showing 25% anterior slippage at L4–5 and sagittal MR image showing spinal canal stenosis corresponding to the spondylolisthesis. B: Flexion-extension radiographs and sagittal MR image obtained 2 years after microendoscopic laminotomy at L4–5. The radiographs show no progression of the spinal instability. The MR image shows that the spinal canal is decompressed at the surgery site. C: Axial CT scan obtained 2 years postoperatively showing preservation of the facet joints at the surgical level.

References

  • 1

    Abumi KPanjabi MMKramer KMDuranceau JOxland TCrisco JJ: Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976) 15:114211471990

  • 2

    Amundsen TWeber HNordal HJMagnaes BAbdelnoor MLilleâs F: Lumbar spinal stenosis: conservative or surgical management?: a prospective 10-year study. Spine (Phila Pa 1976) 25:142414362000

  • 3

    Athiviraham AYen D: Is spinal stenosis better treated surgically or nonsurgically?. Clin Orthop Relat Res 458:90932007

  • 4

    Atlas SJKeller RBRobson DDeyo RASinger DE: Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the Maine Lumbar Spine Study. Spine (Phila Pa 1976) 25:5565622000

  • 5

    Bridwell KHSedgewick TAO'Brien MFLenke LGBaldus C: The role of fusion and instrumentation in the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord 6:4614721993

  • 6

    Fischgrund JSMackay MHerkowitz HNBrower RMontgomery DMKurz LT: 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976) 22:280728121997

  • 7

    Fukuhara SBito SGreen JHsiao AKurokawa K: Translation, adaptation, and validation of the SF-36 Health Survey for use in Japan. J Clin Epidemiol 51:103710441998

  • 8

    Fukui MChiba KKawakami MKikuchi SKonno SMiyamoto M: Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Part 3. Validity study and establishment of the measurement scale: Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association, Japan. J Orthop Sci 13:1731792008

  • 9

    Ghiselli GWang JCBhatia NNHsu WKDawson EG: Adjacent segment degeneration in the lumbar spine. J Bone Joint Surg Am 86-A:149715032004

  • 10

    Grob DHumke TDvorak J: Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am 77:103610411995

  • 11

    Haher TRO'Brien MDryer JWNucci RZipnick RLeone DJ: The role of the lumbar facet joints in spinal stability. Identification of alternative paths of loading. Spine (Phila Pa 1976) 19:266726711994

  • 12

    Herkowitz HNKurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 73:8028081991

  • 13

    Iguchi TKurihara ANakayama JSato KKurosaka MYamasaki K: Minimum 10-year outcome of decompressive laminectomy for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976) 25:175417592000

  • 14

    Ikuta KArima JTanaka TOga MNakano SSasaki K: Short-term results of microendoscopic posterior decompression for lumbar spinal stenosis. Technical note. J Neurosurg Spine 2:6246332005

  • 15

    Izumida SInoue S: [Assessment of treatment for low back pain.]. J Jpn Orthop Assoc 60:3913941986. (Jpn)

  • 16

    Jolles BMPorchet FTheumann N: Surgical treatment of lumbar spinal stenosis. Five-year follow-up. J Bone Joint Surg Br 83:9499532001

  • 17

    Johnsson KERedlund-Johnell IUdén AWillner S: Preoperative and postoperative instability in lumbar spinal stenosis. Spine (Phila Pa 1976) 14:5915931989

  • 18

    Jönsson BAnnertz MSjöberg CStrömqvist B: A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: Clinical features related to radiographic findings. Spine (Phila Pa 1976) 22:293229371997

  • 19

    Kaito THosono NMukai YMakino TFuji TYonenobu K: Induction of early degeneration of the adjacent segment after posterior lumbar interbody fusion by excessive distraction of lumbar disc space. Clinical article. J Neurosurg Spine 12:6716792010

  • 20

    Katz JNLipson SJChang LCLevine SAFossel AHLiang MH: Seven- to 10-year outcome of decompressive surgery for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976) 21:92981996

  • 21

    Kawaguchi YKanamori MIshihara HOhmori KFujiuchi YMatsui H: Clinical symptoms and surgical outcome in lumbar spinal stenosis patients with neuropathic bladder. J Spinal Disord 14:4044102001

  • 22

    Khoo LTFessler RG: Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neurosurgery 51:5 SupplS146S1542002

  • 23

    Kornblum MBFischgrund JSHerkowitz HNAbraham DABerkower DLDitkoff JS: Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis. Spine (Phila Pa 1976) 29:7267342004

  • 24

    Liao JCChen WJChen LHNiu CCKeorochana G: Surgical outcomes of degenerative spondylolisthesis with L5-S1 disc degeneration: comparison between lumbar floating fusion and lumbosacral fusion at a minimum 5-year follow-up. Spine (Phila Pa 1976) 36:160016072011

  • 25

    Matsumoto MHasegawa TIto MAizawa TKonno SYamagata M: Incidence of complications associated with spinal endoscopic surgery: nationwide survey in 2007 by the Committee on Spinal Endoscopic Surgical Skill Qualification of Japanese Orthopaedic Association. J Orthop Sci 15:92962010

  • 26

    McCulloch JAMicrosurgical spinal laminectomies. Frymoyer JW: The Adult Spine: Principles and Practice New YorkRaven Press1991. 18211831

  • 27

    Nakamura MMiyamoto KShimizu K: Validation of the Japanese version of the Roland-Morris Disability Questionnaire for Japanese patients with lumbar spinal diseases. Spine (Phila Pa 1976) 28:241424182003

  • 28

    Nowitzke AM: Assessment of the learning curve for lumbar microendoscopic discectomy. Neurosurgery 56:7557622005

  • 29

    Oertel MFRyang YMKorinth MCGilsbach JMRohde V: Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminotomy for bilateral decompression. Neurosurgery 59:126412702006

  • 30

    Ohtori SIto TYamashita MMurata YMorinaga THirayama J: Evaluation of low back pain using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire for lumbar spinal disease in a multicenter study: differences in scores based on age, sex, and type of disease. J Orthop Sci 15:86912010

  • 31

    Palmer STurner RPalmer R: Bilateral decompression of lumbar spinal stenosis involving a unilateral approach with microscope and tubular retractor system. J Neurosurg 97:2 Suppl2132172002

  • 32

    Pao JLChen WCChen PQ: Clinical outcomes of microendoscopic decompressive laminotomy for degenerative lumbar spinal stenosis. Eur Spine J 18:6726782009

  • 33

    Park PGarton HJGala VCHoff JTMcGillicuddy JE: Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976) 29:193819442004

  • 34

    Perez-Cruet MJFoley KTIsaacs RERice-Wyllie LWellington RSmith MM: Microendoscopic lumbar discectomy: technical note. Neurosurgery 51:5 SupplS129S1362002

  • 35

    Pintar FACusick JFYoganandan NReinartz JMahesh M: The biomechanics of lumbar facetectomy under compression-flexion. Spine (Phila Pa 1976) 17:8048101992

  • 36

    Postacchini FCinotti G: Bone regrowth after surgical decompression for lumbar spinal stenosis. J Bone Joint Surg Br 74:8628691992

  • 37

    Sairyo KSakai THigashino KInoue MYasui NDezawa A: Complications of endoscopic lumbar decompression surgery. Minim Invasive Neurosurg 53:1751782010

  • 38

    Shibayama MMizutani JTakahashi INagao SOhta HOtsuka T: Patch technique for repair of a dural tear in microendoscopic spinal surgery. J Bone Joint Surg Br 90:106610672008

  • 39

    Suzukamo YFukuhara SKikuchi SKonno SRoland MIwamoto Y: Validation of the Japanese version of the Roland-Morris Disability Questionnaire. J Orthop Sci 8:5435482003

  • 40

    Turner JAErsek MHerron LDeyo R: Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine Phila Pa 1976) 17:181992

  • 41

    Weinstein JNLurie JDTosteson TDHanscom BTosteson ANBlood EA: Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 356:225722702007

  • 42

    Yoshida MUeyoshi AMaio KKawai MNakagawa YSurgical procedures and clinical results of endoscopic decompression for lumbar canal stenosis. Dezawa AChen PQChung JY: State of the Art for Minimally Invasive Spine Surgery TokyoSpringer-Verlag2005. 1524

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