Transforaminal arthroscopic decompression of lateral recess stenosis

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✓ The purpose of this study was to evaluate the feasibility and efficacy of arthroscopic decompression of lateral recess stenosis, determine potential associated complications, and present an alternative method to access the lateral recess of the lumbar spine. Forty patients were selected in whom the authors found clinical and computerized tomography evidence of lateral recess stenosis and sequestered foraminal herniations. All 40 were treated with a posterolateral arthroscopic technique, and 38 were available for this follow-up evaluation. A satisfactory result was obtained in 31 patients (82%). No neurovascular complications were encountered; however, other complications included an infection of the disc space in one patient and a causalgic-type pain in the involved extremity in four patients. The associated postoperative morbidity in this group of patients was minimal and resulted in rapid rehabilitation and return of patients to preoperative functioning level.

Article Information

Address reprint requests to: Parviz Kambin, M.D., 1125 Lancaster Avenue, Berwyn, Pennsylvania 19312.

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Figures

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    Schematic drawing showing the anatomy of the lateral recess. Note the contribution of the protruding annulus and marginal osteophytes to the development of the stenosis.

  • View in gallery

    Proper positioning of the guide wire at the onset of the procedure is a prerequisite for successful decompression of the lateral recess. Left: Intraoperative x-ray film showing proper positioning of the guide wire in the foramen at the midpedicular line in anteroposterior projection. Right: Intraoperative x-ray film, lateral view, of the needle position.

  • View in gallery

    Upper Left: Arthroscopic view showing the surgical site, which has been accessed via an oval cannula. Note the traversing nerve root (N) and epidural adipose tissue (top) and the annulectomy site and evacuation of nuclear tissue from underneath the posterior longitudinal ligament (PLL) (bottom). Lower Left: Artist's rendering from intraoperative photograph. Upper Center: Arthroscopic view showing marginal osteophytes arising from the posterior vertebral body and extending to the lateral recess under the exiting root. Lower Center: Artist's rendering. Upper Right: Arthroscopic view showing the site from which the annulus and marginal osteophytes have been resected. Note multiple fenestrations and the spinal nerve (top). Lower Right: Artist's rendering.

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    Upper Left: Intraoperative photograph showing a working channel scope with punch forceps being used for the removal of the severed annulus and nuclear tissue under direct visualization. Lower Left: Artist's rendering from intraoperative photograph. Upper Center: Photograph showing the superficial vein being coagulated through a working channel scope. Lower Center: Artist's rendering. Upper Right: Arthroscopic view showing the spinal canal. Note that the arthroscope is directed toward the axilla of the traversing nerve root. The dural sac (D) (top), the Hoffman and dural ligaments (L) (middle), and the traversing nerve root (N) (bottom) can all be seen. Lower Right: Artist's rendering.

  • View in gallery

    Left: Preoperative computerized tomography (CT) scans revealing asymmetrical disc protrusion extending to the left lateral recess at L4–5 that was associated with both L-4 and L-5 radiculopathy. Right: Immediate postoperative CT scan indicating the proper position of the Hemovac tube in the path of the previously inserted cannula, which was used for annular resection and subcapsular decompression of the paramedial disc protrusion. Note that the Hounsfield number at the site of protrusion (2) is reduced to 1.0. The Hounsfield number on the annulus, away from the surgical site (1), is 76.3 and the dural sac (3) is 4.3.

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