Elsevier

World Neurosurgery

Volume 145, January 2021, Pages 631-642
World Neurosurgery

Endoscopic Spine Surgery Special Section
Indication and Contraindication of Endoscopic Transforaminal Lumbar Decompression

https://doi.org/10.1016/j.wneu.2020.03.076Get rights and content

Background

The indications and contraindications to the endoscopic transforaminal approach for lumbar spinal stenosis are not well defined.

Methods

We performed a Kaplan-Meier durability survival analysis of patients with the following types of spinal stenosis: type I, central canal; type II, lateral recess; type III, foraminal; and type IV, extraforaminal. The 304 patients comprised 140 men and 164 women, with an average age of 51.68 ± 15.78 years. The average follow-up was 45.3 years (range, 18–90 years). The primary clinical outcome measures were the Oswestry Disability Index, visual analog scale, and the modified Macnab criteria.

Results

Of 304 study patients, 70 had type I (23.0%) stenosis, 42 type II (13.7%), 151 type III (49.7%), and 41 type IV (13.5%). Excellent outcomes were obtained in 114 patients (37.5%), good in 152 (50.0%), fair in 33 (10.9%), and poor in 5 (1.6%). Kaplan-Meier durability analysis of the clinical treatment benefit with the endoscopic transforaminal decompression surgery showed statistically significance differences (P < 0.0001) on log-rank (Mantel-Cox) χ2 testing between the estimated median (50% percentile) survival times of type I (28 months), type II (53 months), type III (32 months), and type IV (66 months).

Conclusions

We recommend stratifying patients based on the underlying compressive disease and the skill level of the endoscopic spine surgeon to decide preoperatively whether more difficult central or complex foraminal stenotic lesions should be considered for alternative endoscopic approaches.

Introduction

Spinal stenosis is one of the most effective indications for surgery in the lumbar spine.1, 2, 3, 4, 5, 6 With the increase in life expectancy and changes in societal expectation of higher functioning, on the whole, spine surgery is performed at a higher rate, and advanced age alone is no longer a contraindication for surgery.7, 8, 9 Risk factors with surgery in the lumbar spine in the elderly are similar to those in younger patients with most unintended postoperative hospital readmission taking place because of poorly managed medical comorbidities rather than surgical site problems.10, 11, 12 Endoscopic spine surgery is an attractive alternative to open surgery because it is associated with a lower risk of dural tears, nerve injuries, postoperative cardiopulmonary problems, and complication rates compared with those reported with traditional open translaminar surgery.13,14

Because endoscopic spinal surgery is gaining more traction among traditional spine surgeons, the debate about appropriate patient selection criteria for the transforaminal decompression procedure will likely intensify. Although still not well accepted by traditionally trained spine surgeons, transforaminal decompression can be disruptive and disparative to those surgeons who had no endoscopic training during their surgical residencies. The expertise is often developed self-guided by individual interest and self-motivation. Many endoscopic surgeons discover that anatomic considerations, such as a high-riding ilium or obliterated lateral access to the L5/S1 neuroforamen caused by a hypertrophied superior or inferior articular process or sacral alar may affect preoperative planning for the most suitable access to the painful compressive disease. Additional problems may arise from transitional anatomy and other variations of normal anatomy that may obliterate the transforaminal access to the neuroforamen, lateral recess, and spinal canal. For example, a low pelvic incidence or a high sacral slope may make access to the intervertebral disc space difficult as well. Moreover, often, the natural aging of the lumbar spine obliterates landmarks and distorts the otherwise familiar normal anatomy. Using a well-thought-out algorithm stratifying patients preoperatively most suitable for the endoscopic decompression technique in our opinion is of critical importance to achieving favorable clinical outcomes with high consistency.15

Defining the indications and contraindications to endoscopic transforaminal decompression surgery in patients with sciatica-type low back and leg pain was at the heart of this study. Therefore, we used a previously vetted and published image-based algorithm stratifying patients into 4 types of spinal stenosis, thereby more accurately taking the extent and location of the symptomatic compressive disease into consideration, as well as access constraints dictated by the patient's anatomy at the surgical level.15 We analyzed clinical outcomes and their durability as defined by the absence of additional treatments at the same index level and side with Kaplan-Meier (K-M) survival analysis over 6 years by including only patients with a minimum 2-year follow-up using the Oswestry Disability Index (ODI),16 visual analog scale (VAS),17 and modified Macnab criteria18 as the primary clinical outcome measures.

Section snippets

Patients

All patients in this case series had sciatica-type low back and leg pain with claudication symptoms caused by bony and soft tissue spinal stenosis from facet joint and ligamentum flavum hypertrophy with lumbar disc herniation contributing to stenosis in the central canal, the lateral recess, the foramen, and the extraforaminal area under the exiting nerve root. This retrospective study consisted of groups of consecutive patients seen in the clinics of the participating study sites. All patients

Results

Analysis of the level distribution shows that L4/5 (137/304; 45.1%) and L5/S1 (96/304; 31.6%) followed by the L3/4 level (18/304; 5.9%) were the levels most commonly operated on. The remaining levels and combinations thereof were operated on at a lower frequency (Table 1). Most patients had surgery for a paracentral herniated disc (124 patients), which contributed to symptomatic spinal stenosis. Another 109 patients were treated for spinal stenosis with a contributing posterolateral disc

Discussion

Patient selection for endoscopic spinal surgery is critical to ensure the clinical success of the procedure.30, 31, 32 Identifying the painful compressive anatomy during preoperative decision making has been reported as the most important goal of the diagnostic workup before transforaminal endoscopic surgery.31 In general, the indications for surgery are defined by unrelenting radiculopathy and neurogenic claudication symptoms nonresponsive to medical and interventional care, physical therapy,

Conclusions

We used a previously reported and thorough peer-review-vetted 4-zone stenosis protocol that was useful in aiding in selecting the appropriate surgical patients for the transforaminal endoscopic decompression procedure to treat common painful lumbar spine disease in the central canal (type I), lateral recess (type II), foraminal (type III), and extraforaminal (type IV) zone.15) Formulating the best indications and contraindications to transforaminal endoscopic decompression depends on the

CRediT authorship contribution statement

Kai-Uwe Lewandrowski: Conceptualization, Methodology, Project administration, Resources, Formal analysis, Writing - original draft. Álvaro Dowling: Conceptualization, Methodology, Project administration, Resources, Formal analysis, Writing - original draft. Paulo Sérgio Teixeira de Carvalho: Resources, Writing - original draft. Thiago Soares dos Santos: Resources, Writing - original draft. Marlon Sudário de Lima e Silva: Resources, Writing - original draft. Jorge Felipe Ramírez León: Resources,

References (32)

  • E. Hermansen et al.

    Clinical outcome after surgery for lumbar spinal stenosis in patients with insignificant lower extremity pain. A prospective cohort study from the Norwegian registry for spine surgery

    BMC Musculoskelet Disord

    (2019)
  • R.T. Paulsen et al.

    Prognostic factors for satisfaction after decompression surgery for lumbar spinal stenosis

    Neurosurgery

    (2018)
  • M. Raad et al.

    Trends in isolated lumbar spinal stenosis surgery among working US adults aged 40-64 years, 2010-2014

    J Neurosurg Spine

    (2018)
  • A. Antoniadis et al.

    Decompression surgery for lumbar spinal canal stenosis in octogenarians; a single center experience of 121 consecutive patients

    Br J Neurosurg

    (2017)
  • C. Giannadakis et al.

    Surgery for lumbar spinal stenosis in individuals aged 80 and older: a multicenter observational study

    J Am Geriatr Soc

    (2016)
  • P. Forsth et al.

    Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: a two-year follow-up study involving 5390 patients

    Bone Joint J

    (2013)
  • Cited by (15)

    • Contraindications and Complications of Full Endoscopic Lumbar Decompression for Lumbar Spinal Stenosis: A Systematic Review

      2022, World Neurosurgery
      Citation Excerpt :

      There is no RCT that can compare transforaminal and interlaminar decompression to compare complications and contraindications; therefore, direct meta-analysis was not possible for both methods, and only descriptive analysis was performed. As for the articles analyzing the contraindication for full endoscopic lumbar decompression, there are 4 studies of systematic review of contraindications of full endoscopic lumbar decompression.14-17 ( Table 1).

    • The Italian Landscape of Spine Endoscopy: Are We Ready for the Challenges of the Future?

      2024, Journal of Minimally Invasive Spine Surgery and Technique
    View all citing articles on Scopus

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    View full text