Elsevier

World Neurosurgery

Volume 145, January 2021, Pages 657-662
World Neurosurgery

Endoscopic Spine Surgery Special Section
Indications and Contraindications of Full-Endoscopic Interlaminar Lumbar Decompression

https://doi.org/10.1016/j.wneu.2020.08.042Get rights and content

Background

Spinal stenosis is a common disease with an increasing incidence. Narrowing of the spinal canal is caused by bone and soft tissue degeneration, such as osteophyte formation, facet and ligamentum flavum hypertrophy, and disc herniation. Various surgical techniques have been used to treat spinal canal stenosis, including open, tubular, microsurgical decompression, and fusion surgery. This article presents the technique for full-endoscopic interlaminar bilateral decompression of the lumbar spine.

Methods

Surgical approach, anatomy, pathology, indications, contraindications, and surgical equipment are described.

Results

With well-chosen endoscopic equipment, surgical time can be reduced with minimal collateral damage. Clear advantages of full-endoscopic decompression over open or other minimally invasive surgery methods are demonstrated in many clinical studies. The endoscopic technique has been shown to be effective in spinal canal decompression with good to excellent clinical results. The interlaminar endoscopic approach minimizes iatrogenic injury to the stabilizing anatomic structures while achieving full unilateral and bilateral decompression. A significant improvement in pain and functional outcome scores with low complication rates has been demonstrated.

Conclusions

This technique is safe for lumbar spinal decompression and more minimally invasive than a microendoscopic approach. However, this technique should be performed by surgeons with advanced skills. Endoscopy could become the gold standard for treatment of canal stenosis in the near future.

Introduction

Lumbar spinal stenosis is a common disease with an increasing incidence. Narrowing of the spinal canal leads to neurogenic claudication as the main symptom. Mainly middle-aged and older adults have lumbar leg and back pain with a negative impact on activity level and quality of life requiring spinal surgery.1 According to a meta-analysis by Jensen et al.,2 the mean prevalence estimates for lumbar spinal stenosis based on clinical diagnoses vary between 11% and 39%. Tomkins-Lane et al.1 reported that the prevalence of lumbar spinal stenosis is estimated to be 9% in the general population and up to 47% in people >60 years of age.

Spinal stenosis is divided into 3 different entities, central spinal canal stenosis, lateral recess stenosis, and foraminal stenosis, according to the anatomic location of the compression. The onset of pain associated with spinal stenosis includes mechanical/biomechanical, neural, vascular, and inflammatory causes. Hypertrophy of the articular process and yellow ligament and disc herniation are the main reasons for worsening of the clinical symptoms of lumbar stenosis. The extent of stenosis observed in imaging procedures does not have to correlate with the clinical symptoms.3, 4, 5

Various surgical techniques have been used for the treatment of spinal canal stenosis, including tubular and microsurgical decompression and fusion surgery.6 With the development of endoscopic techniques for decompression of the lumbar spine, alternative treatment options with less tissue trauma, lower costs, and similar or better results have been developed, especially for older patients.7, 8, 9 A targeted and pathology-oriented approach is the key to success to ensure the therapeutic effect.10 The most important full-endoscopic techniques are the transforaminal and interlaminar approaches.8,11,12 Transforaminal endoscopic techniques have been reported to be successful in disc surgery and unilateral foraminal stenosis, but there are anatomic limitations for symptomatic bilateral recess stenosis. These limitations, especially at the level of L5-S1, are a high iliac crest, a large L5 transverse process, a large facet joint, and a narrowed disc space.13

The interlaminar endoscopic technique is similar to tubular decompression surgery, meaning the anatomic orientation is familiar and similar in both techniques.14 Full-endoscopic interlaminar decompression shows that all the procedures of open decompression can be completely substituted by endoscopic management.15 With advances in endoscopic spinal surgery methods and instruments, earlier contraindications have become indications for full-endoscopic spinal decompression in the treatment of lumbar degenerative diseases. Advantages are reduced destruction of the structures and preservation of stability while achieving full unilateral and bilateral decompression.16

Section snippets

Indications

Interlaminar techniques are indicated for disc herniation, lateral recess stenosis, central canal stenosis, ligamentum flavum hypertrophy, facet joint cysts and hypertrophy, foraminal pathologies, and adhesions.

Anesthesia and Patient Positioning

The procedure is performed with the patient in prone position. The available anesthesia options are local or general anesthesia. A possible scheme for conscious sedation is a combination of midazolam, remifentanil, and oxygen via nasal cannula. The drugs are dosed individually by

Discussion

Systematic reviews and meta-analyses prove the therapeutic effects of full-endoscopic lumbar discectomy to be superior or at least equivalent compared with standard open lumbar microdiscectomy. Measured clinical outcome parameters are success rate, complication rate, recovery time, visual analog scale, MacNab criteria, operative time, and patient satisfaction.17, 18, 19, 20 The surgical approach depends on the location and the type of pathology. The access method finally chosen should be the

Conclusions

Clear advantages of full-endoscopic decompression over open or other minimally invasive surgery methods are demonstrated in many clinical studies. Minimal iatrogenic trauma to muscles and stabilizing structures, less blood loss, shorter hospital stay, quick recovery, minimal scar tissue, and fewer complications have been demonstrated. Significant improvement in pain and functional outcome scores with low complication rates have been demonstrated. Direct visualization helps to prevent nerve root

CRediT authorship contribution statement

Ralf Wagner: Methodology, Writing - original draft, Investigation. Monika Haefner: Conceptualization, Writing - review & editing.

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

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      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).

    • Comparison Between Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression and Other Decompression Approaches for Lumbar Spinal Stenosis: A Systematic Review

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      In 2006, Ruetten et al.5 developed the interlaminar approach for overcoming the limitations of the transforaminal approach and minimizing trauma, substantially expanding the spectrum for full-endoscopic (FE) surgery. In their review, Wagner and |Haefner6 described the indications and contraindications for lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD). LE-ULBD enables surgeons to perform multilevel and contralateral decompression and use scopes of different sizes; these advantages can expand indications for LE-ULBD.

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    Conflict of interest statement: R. Wagner is a joimax faculty member. M. Haefner is an employee of joimax GmbH.

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