Elsevier

The Spine Journal

Volume 15, Issue 10, 1 October 2015, Pages 2282-2289
The Spine Journal

Technical Report
Irrigation endoscopic decompressive laminotomy. A new endoscopic approach for spinal stenosis decompression

https://doi.org/10.1016/j.spinee.2015.07.009Get rights and content

Abstract

Background context

The classic surgical treatment of spinal stenosis involves bilateral dissection of paraspinal muscles to expose all the involved levels, wide laminectomy, and medial facetectomy and foraminotomy. The surgical morbidity of the procedure is further magnified by being more common in elderly with associated medical comorbidities and being usually global involving multiple levels. To address this problem, several less invasive techniques have been introduced over the past decade including the microendoscopic decompression.

Purpose

The aim was to describe and evaluate a new endoscopic technique for lumbar spinal canal decompression named irrigation endoscopic decompressive laminotomy.

Study design

This was a technical report.

Patient sample

One hundred four consecutive patients suffering from neurogenic claudication and resistant to 3 months of conservative management were included in the study. Grade I degenerative spondylolisthesis and degenerative scoliosis were not considered a contraindication. Patients with segmental instability and predominant low back pain were excluded.

Outcome measures

Primary outcome measures included the final functional outcome using modified Macnab criteria and the Oswestry Disability Index (ODI). In addition, the operative time and complication rate have been evaluated. Secondary outcome measures included the evaluation of the early postoperative course using visual analog scale for postoperative incisional pain, time for ambulation, and length of hospital stay.

Methods

Two 0.5-cm portals were used, one for the endoscope and the other for instruments. For every additional level, one portal is added. The endoscope and instruments are directly placed over the surface of lamina without any dissection, and saline under pump pressure is used to open a potential working space. Unilateral laminotomy/laminectomy is performed according to the severity of stenosis, followed by bilateral decompression beneath the midline structures.

Results

Mean follow-up period was 28 months. The final outcome was excellent in 63%, good in 24%, fair in 9%, and poor in 4%. The preoperative ODI dropped from a mean of 64.2±10.0 to 23.1±20.8 postoperatively. Complications were limited to six cases of dural tear, which required no open conversion.

Conclusions

Irrigation endoscopic decompressive laminotomy allows the surgeon to safely perform effective central and foraminal decompression resulting in satisfactory midterm clinical results. Substituting long surgical incisions with 0.5-cm stabs and direct placement of instruments without dissection or dilatation could result in an improved postoperative course, shortened time for hospitalization, and reduced infection rate. However, still multicenter studies and randomized trials are needed before making final conclusions.

Introduction

Spinal canal stenosis is the most common indication for lumbar spine surgery in adults older than 65 years [1]. The traditional surgical treatment involves bilateral dissection of paraspinal muscles to expose all the involved levels, removal of the supraspinous and interspinous ligaments, wide laminectomy, and medial facetectomy with foraminotomy [2]. Frequent failures have been attributed to paraspinal muscle atrophy and denervation resulting in potential chronic pain [3], [4] and to the increased incidence of postoperative spinal instability [4], [5], [6], [7], [8], [9].

To overcome these problems and reduce the time for hospitalization and postoperative recovery, several less invasive techniques have been introduced including multiple laminotomies, chimney sublaminar decompression [10], [11], [12], and the “ over the top technique,” which describes bilateral spinal decompression using an ipsilateral hemilaminotomy and contralateral decompression beneath the midline structures [13], [14]. This technique was later modified by the introduction of the endoscope through a tubular retractor and named microendoscopic decompressive laminotomy [15], [16], [17].

In the current clinical series, a new minimally invasive procedure for spinal canal decompression named the irrigation endoscopic decompressive laminotomy (IEDL) is presented. The latter is based on the irrigation endoscopic discectomy technique [18] where the endoscope and instruments were directly placed over the surface of the lamina through 0.5-cm skin portals without any muscle stripping or dilatation. This is followed by spinal canal decompression using “over the top technique” under continuous endoscopic vision.

The purposes of the present study were to evaluate the results of decompression using the IEDL technique and assess its effect on the postoperative course.

Section snippets

Materials and methods

The study was conducted after the approval of the institutional review board. All patients signed a consent that they will be enrolled in clinical study involving a new endoscopic technique for spinal canal decompression.

Primary outcome measures were assessed using the Oswestry Disability Index (ODI) [19] and the modified Macnab criteria [20]. In addition, the operative time and complication rate were evaluated. Secondary outcome measures included the extent of surgical invasion, which has been

Results

From September 2009 to December 2011, a total of 104 consecutive patients were operated in our institution. Baseline patient demographics and disease characteristics are summarized in (Table 3).

The mean follow-up period was 28 months. Ten cases were lost at the time of final follow-up, two died of irrelevant disease, and eight did not respond to our attempts of contact by phone or mail, giving a 90% of follow-up data available.

The mean operative time was 62.8 min/level, and the estimated blood

Discussion

Traditional treatment of spinal stenosis involved bilateral retraction of the paraspinal muscles, wide laminectomy, medial facetectomy and foraminotomy. Frequent surgical failures have been attributed to local tissue trauma [3], [4], postoperative spinal instability [4], [5], [7], [9], which has led to marked increase in lumbar fusion surgery [23].

On the other hand, the target of minimally invasive spine surgery has always been to reduce approach-related morbidity, aiming the improvement of the

Conclusions

From our initial experience, we conclude that the IEDL enables the surgeon to perform complete decompression of the neurologic structures under excellent illumination and magnification. Success rates similar to open decompression have been achieved. Meanwhile, significant reduction of the surgical morbidity has been observed. This would be of special value in cases of spinal stenosis where patients are usually of an elderly age group with associated medical comorbidities and a disease usually

References (39)

  • P. Shih et al.

    Complications of open compared to minimally invasive lumbar spine decompression

    J Clin Neurosci

    (2011)
  • F. Asgarzadie et al.

    Minimally invasive operative management for lumbar spinal stenosis: overview of early and long-term outcomes

    Orthop Clin North Am

    (2007)
  • J.N. Weinstein et al.

    Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis

    N Engl J Med

    (2007)
  • L.L. Wiltse et al.

    The treatment of spinal stenosis

    Clin Orthop Relat Res

    (1976)
  • O. Airaksinen et al.

    Density of lumbar muscles 4 years after decompressive spinal surgery

    Eur Spine J

    (1996)
  • B.K. Weiner et al.

    Microdecompression for lumbar spinal canal stenosis

    Spine

    (1999)
  • M.W. Fox et al.

    Clinical outcomes and radiological instability following decompressive lumbar laminectomy for degenerative spinal stenosis: a comparison of patients undergoing concomitant arthrodesis versus decompression alone

    J Neurosurg

    (1996)
  • K.E. Johnsson et al.

    Postoperative instability after decompression for lumbar spinal stenosis

    Spine

    (1986)
  • T.J. Kleeman et al.

    Patient outcomes after minimally destabilizing lumbar stenosis decompression: the ‘‘port-hole’’ technique

    Spine

    (2000)
  • O. Nakai et al.

    Long-term roentgenographic and functional changes in patients who were treated with wide fenestration for central lumbar stenosis

    J Bone Joint Surg Am

    (1991)
  • G.F. Tuite et al.

    Outcome after laminectomy for lumbar spinal stenosis. Part II: radiographic changes and clinical correlations

    J Neurosurg

    (1994)
  • J. Aryanpur et al.

    Multilevel lumbar laminotomies: an alternative to laminectomy in the treatment of lumbar stenosis

    Neurosurgery

    (1990)
  • J.A. McCulloch
  • S. Young et al.

    Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy: preliminary report

    Neurosurgery

    (1988)
  • H. Cavusoglu et al.

    Midterm outcome after unilateral approach for bilateral decompression of lumbar spinal stenosis: 5-year prospective study

    Eur Spine J

    (2007)
  • F. Costa et al.

    Degenerative lumbar spinal stenosis: analysis of results in a series of 374 patients treated with unilateral laminotomy for bilateral microdecompression

    J Neurosurg

    (2007)
  • L.T. Khoo et al.

    Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis

    Neurosurgery

    (2002)
  • J.L. Pao et al.

    Clinical outcomes of microendoscopic decompressive laminotomy for degenerative lumbar spinal stenosis

    Eur Spine J

    (2009)
  • H.M. Soliman

    Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse

    Eur Spine J

    (2013)
  • Cited by (89)

    • Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Meta-Analysis and Systematic Review

      2023, World Neurosurgery
      Citation Excerpt :

      This may be related to intraoperative high hydrostatic pressure causing compression of the nerve root when the procedure is too long, and high hydrostatic pressure also increases intracranial pressure,34 which can lead to headaches.8 So, we abort the procedure for 3 minutes every 30 minutes if necessary to ensure the safety of the procedure.20 In addition, transient palsy may also be related to postoperative nerve root oedema, mild compression of the hematoma or incomplete nerve root injury.

    View all citing articles on Scopus

    FDA device/drug status: Not applicable.

    Author disclosures: HMS: Nothing to disclose.

    The study has been conducted after approval of the institutional review board: CUK-O221209.

    There was no source of external funding for this study.

    View full text