Endoscope-assisted spinal decompression surgery for lumbar spinal stenosis

Technical note

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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).


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.


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.


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.



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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.


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