Endoscopic Spine Surgery Special SectionIndication and Contraindication of Endoscopic Transforaminal Lumbar Decompression
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,
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Contraindications and Complications of Full Endoscopic Lumbar Decompression for Lumbar Spinal Stenosis: A Systematic Review
2022, World NeurosurgeryCitation 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).
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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.