Elsevier

The Spine Journal

Volume 21, Issue 1, January 2021, Pages 122-133
The Spine Journal

Clinical Study
Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

https://doi.org/10.1016/j.spinee.2020.08.010Get rights and content

ABSTRACT

Background Context

Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).

Purpose

To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).

Study Design/Setting

Prospective cohort study.

Patient Sample

One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.

Outcome Measures

Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.

Methods

A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.

Results

The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.

Conclusions

LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.

Introduction

Degenerative lumbar central canal stenosis (DLCS) is caused by narrowing of the spinal canal. Typical symptoms of DLCS include low back pain and leg pain, which affect patients’ quality of life and drastically restrict functions. Among all spinal surgeries, DLCS is the most common etiology [1,2]. Numerous studies have indicated that surgical treatment results in better outcomes than conservative alternatives [3,4]. The traditional treatment option for DLCS is laminectomy [5]. The open method has good outcomes, but soft tissue violation is tremendous and may lead to iatrogenic instability [6]. Various studies have reported that limiting the extent of bony decompression or preserving posterior midline structures can result in better outcomes [7]. In addition, increasing efforts have been made to establish a solid fusion procedure. In a study on the 4-year results of the Spine Patient Outcomes Research Trial, authors reported that in patients with degenerative spondylolisthesis (DSL) and associated DLCS, no consistent differences in clinical outcomes were observed among different fusion groups [8]. Although fusion techniques provide proper stability to adjacent structures, through a randomized, controlled trial, Försth et al. reported that decompression surgery plus fusion surgery did not result in better clinical outcomes in comparison with decompression surgery alone [9]. Furthermore, decompression alone is more cost effective and is also associated with less operative time and blood loss [10]. Consequently, some less invasive approaches have been explored; for example, unilateral laminotomy for bilateral decompression (ULBD) has been proposed to be a less invasive technique for DLCS treatment compared with conventional laminectomy [11]. Satisfactory results for low back pain, lower extremity pain, and numbness in patients with DLCS treated with ULBD have been reported [12], [13], [14], [15].

Percutaneous endoscopic laminar discectomy (PELD) including percutaneous endoscopic transforaminal discectomy and percutaneous endoscopic interlaminar discectomy has been used for the treatment of lumbar disc herniation since 1975 [16]. Due to the advancement of instrument, lumbar endoscopic ULBD (LE-ULBD) by the uniportal, unilateral approach has been reported to achieve similar outcomes and with less complications than those achieved with open ULBD [17,18]. Moreover, LE-ULBD is associated with least traumatization and is the most minimally invasive method in comparison with conventional percutaneous discectomy. In this study, we investigated the outcomes of LE-ULBD and the feasibility of this approach for different types of DLCS, including simple DLCS, DLCS with DSL, and DLCS with degenerative scoliosis (DSC).

Section snippets

Study cohort and methods

We conducted this study in accordance with the ethical standards of the Institutional Review Board (CYCH104113) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. We prospectively collected data pertaining to 116 patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017. Patients undergoing LE-ULBD were selected based on the following inclusion criteria: (1) failure of conservative treatment with medication and

Results

Herein, we evaluated a total of 106 patients (44 men and 62 women, Table 1). The mean age of patients who underwent surgery was 69.5±9.6 years, and the mean follow-up period was 33.3±8.53 months. Among 106 patients, 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. No patient presented with a combination of DSL and DSC. Fifty-five (48.1%) patients showed one-level stenosis, 47 (44.3%) showed two-level stenosis, and four (3.8%) showed three-level

Discussion

After the development of percutaneous lateral discectomy of the lumbar spine by Kambin and Gellman [31] in 1983 and that of percutaneous nucleotomy for lumbar disc herniation by Hijikata et al. [32] in 1975 with the use of a “nucleoscope” to visualize the intervertebral disc space by Hausmann and Forst [33] in 1983, the first case of endoscopic discectomy was finally described in 1988 [34]. Since then, percutaneous endoscopic surgery has become an alternative technique for spinal pathologies.

Conclusions

LE-ULBD shared the same indications with minimally invasive ULBD. Nonetheless, indications have widened considering the evolvement of surgical skills and novel instrumentation. Our study showed that LE-ULBD is a feasible treatment method for DLCS. Meanwhile, LE-ULBD did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared to LE-ULBD for cases with simple DLCS. More studies are warranted to investigate detailed postoperative outcomes of LE-ULBD.

Acknowledgments

The authors thank to Ms. Sz-Ping Huang for assisting data collection, Miss Yi-Ching Lai and Ms. Yu-Yin Wei for assisting the language editing. This manuscript was edited by Wallace Academic Editing. The current study was approved by the Institutional Review Board (IRB) of our medical institution (CYCH104113). Financial support from Taipei Medical University Hospital (106IIT01, MHW) are highly appreciated. The other authors had no conflict of interest.

References (57)

  • M Du Bois et al.

    A decade's experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000-2009

    Eur Spine J

    (2012)
  • SP Malmivaara A et al.

    Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial

    Spine (Phila Pa 1976)

    (2007)
  • TT Weinstein JN et al.

    Surgical versus nonsurgical therapy for lumbar spinal stenosis

    N Engl J Med

    (2008)
  • JN Gibson et al.

    Surgery for degenerative lumbar spondylosis

    Cochrane Database Syst Rev

    (2005)
  • CS Celik SE et al.

    Microdecompressive laminotomy with a 5-year follow-up period for severe lumbar spinal stenosis

    J Spinal Disord Tech

    (2010)
  • JW Overdevest GM et al.

    Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis

    Cochrane Database Syst Rev

    (2015)
  • LJ Abdu WA et al.

    Degenerative spondylolisthesis: does fusion method influence outcome? Four-year results of the spine patient outcomes research trial

    Spine (Phila Pa 1976)

    (2009)
  • P Forsth et al.

    A randomized, controlled trial of fusion surgery for lumbar spinal stenosis

    N Engl J Med

    (2016)
  • H Inose et al.

    Comparison of decompression, decompression plus fusion, and decompression plus stabilization for degenerative spondylolisthesis

    Clin Spine Surg

    (2018)
  • S Young et al.

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

    Neurosurgery

    (1988)
  • MF Oertel et al.

    Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminotomy for bilateral decompression

    Neurosurgery

    (2006)
  • WS Choi et al.

    Spinal canal morphology and clinical outcomes of microsurgical bilateral decompression via a unilateral approach for lumbar spinal canal stenosis

    Eur Spine J

    (2014)
  • H Cavusoglu et al.

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

    Eur Spine J

    (2007)
  • Y Arai et al.

    A prospective comparative study of 2 minimally invasive decompression procedures for lumbar spinal canal stenosis: unilateral laminotomy for bilateral decompression (ULBD) versus muscle-preserving interlaminar decompression (MILD)

    Spine (Phila Pa 1976)

    (2014)
  • S Hasan et al.

    Comparison of full-endoscopic and minimally invasive decompression for lumbar spinal stenosis in the setting of degenerative scoliosis and spondylolisthesis

    Neurosurg Focus

    (2019)
  • M Komp et al.

    Bilateral operation of lumbar degenerative central spinal stenosis in full-endoscopic interlaminar technique with unilateral approach: prospective 2-year results of 74 patients

    J Spinal Disord Tech

    (2011)
  • KR Chin et al.

    Risk of progression in de novo low-magnitude degenerative lumbar curves: natural history and literature review

    Am J Orthop (Belle Mead NJ)

    (2009)
  • N Evans et al.

    Management of symptomatic degenerative low-grade lumbar spondylolisthesis

    EFORT Open Rev

    (2018)
  • Cited by (0)

    FDA device/drug status: Not applicable.

    Author disclosures: MHW: Taipei Medical University Hospital (106IIT01) (C). PCW: Nothing to disclose. CYL: Nothing to disclose. YKL: Nothing to disclose. TJH: Nothing to disclose. CLL: Nothing to disclose. CHL: Nothing to disclose. YHH: Nothing to disclose.

    #

    These authors contributed equally to this work.

    Corresponding author. Department of Orthopaedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, No. 539, Zhongxiao Rd, East Dist., Chiayi City 60002, Taiwan. Tel.: (88) 65-2765041.

    View full text