Skip to main content
  • Research article
  • Open access
  • Published:

Percutaneous transforaminal full endoscopic decompression for the treatment of lumbar spinal stenosis

Abstract

Background

One advantage of an endoscopic approach to treating lumbar spinal stenosis is preservation of spine stability and the adjacent anatomy, and there is a decrease in adjacent segment disc degeneration. The purpose of this study was to discuss the clinical efficacy of percutaneous transforaminal endoscopic decompression for the treatment of lumbar spinal stenosis (LSS).

Methods

This is a retrospective study. From September 2012 to June 2017, 45 patients who were diagnosed with LSS underwent the treatment of percutaneous transforaminal endoscopic decompression (PTED) and were followed up at 1 week, 3 months and 1 year postoperatively. Low back pain and leg pain were measured by Visual Analogue Scale scoring methods (VAS-back and VAS-leg), while functional outcomes were assessed by using the Oswestry Disability Index (ODI). All patients had one-level lumbar spinal stenosis.

Results

The most common type of stenosis was lateral recess stenosis (n = 22; 48.9%), followed by central stenosis (n = 13; 28.9%) and foraminal stenosis (n = 10: 22.2%). Regarding comparisons of VAS-back, VAS-leg, and ODI scores before and after operation, VAS and ODI scores significantly improved. The average leg VAS score improved from 7.01 ± 0.84 to 2.28 ± 1.43 (P < 0.001). The average ODI improved from 46.18 ± 10.11 to 14.40 ± 9.59 (P < 0.001). We also examined changes in ODI and VAS scores from baseline according to types of spinal stenosis, stenosis grade, spinal instability, and revision surgery in the same segment. The improvement percentage of leg VAS score was significantly less in patients with severe stenosis at both 3 months and 1 year postoperatively. The improvement percentages of ODI and leg VAS scores were significantly less in patients who had spinal instability and patients who had undergone revision surgery.

Conclusion

The PTED approach seems to give good results for the treatment of LSS. However, this approach may be less effective for LSS patients who have lumbar instability or require revision surgery in the same segment.

Peer Review reports

Introduction

Lumbar spinal stenosis (LSS) is a lumbar vertebrae disease resulting from degenerative changes caused by the narrowing of the central canal, the lateral recess, or neural foramen [1]. LSS is more commonly diagnosed in an aging population. Both surgical and conservative approaches have been used for the management of LSS. A surgical approach is recommended if well-conducted conservative management fails. It has been suggested that percutaneous endoscopic discectomy may be an efficient alternative to conventional open lumbar decompression surgery when treating lumbar spinal stenosis [2]. The argument for this is that open decompressions for spinal stenosis have a high complication rate and are painful to recover from but endoscopic techniques for decompressing herniated discs have shown low complication and morbidity rates.

It is a challenging task to initially manage degenerative spine disease in patients with advanced age and multiple comorbidities. Both percutaneous endoscopic discectomy and decompression have yielded optimal results and favorable long-term outcomes in patients over 70 years old who had various types of stenosis [3]. Percutaneous transforaminal endoscopic lumbar discectomy (PTED) is one of the most popular minimally invasive spine surgeries. It has been widely used for treating lumbar degenerative diseases. Although PTED is mainly conducted in elderly patients, the clinical efficacy of PTED in treating patients aged younger than 45 years who have lumbar disc herniation has been proved [4]. The endoscopic approach is considered as a safe and effective minimally invasive surgery [5, 6]. It is associated with better outcomes, small incisions, less damage to human tissues, lower complication rate, and shorter hospitalization times [7, 8]. Lumbar interbody fusion surgery has the advantages of a high fusion rate and an obvious decompression effect, but it causes great damage to the paravertebral muscles and facet joints. It has been reported that adjacent segment disc degeneration may occur due to increased mechanical stress on discs adjacent to the fusion. Besides, elderly patients with severe osteoporosis were prone to internal fixation failure after pedicle screw fixation [9]. One advantage of the endoscopic approach is the preservation of spine stability and the adjacent anatomy, and there is a decrease in adjacent segment disc degeneration. It has been argued whether decompression alone or decompression with concomitant fusion yields better results when treating LSS, and only a few studies investigated the curative effect of PTED for the treatment of LSS. Therefore, this study aimed to evaluate the clinical efficacy of PTED and to find out the prognostic factors of PTED for the treatment of LSS.

Material and method

This is a retrospective study, and the Institutional Review Board of the Third Affiliated Hospital of Sun Yat-Sen University approved the study. The requirement for informed consent from each patient to use their clinical data for research purposes was waived. Patients were included if they had met all of the following inclusion criteria: 1) neurogenic intermittent claudication or radicular irritation with or without sensory loss; 2) unilateral radiating leg pain; 3) concordant imaging diagnosis of lumbar stenosis; 4) failure of conservative treatment for at least 3 months. The patients were excluded from this study if they had 1) potential mental illness; 2) a grade 2 lumbar spondylolisthesis; 3) multilevel lumbar spinal stenosis; or 4) severe scoliosis. From September 2012 to June 2017, a total of 45 patients with unilateral lumbar stenosis were consecutively enrolled. All of them met the inclusion criteria and were treated with percutaneous transforaminal endoscopic decompression.

Imaging

All patients were evaluated before the operation via computed tomography (CT) and magnetic resonance imaging (MRI). The severity of LSS was graded based on the observed morphology of the dural sac on image findings (Fig. 1) according to the method by Schizas [10]. We defined grade A as mild stenosis, B as moderate stenosis, C as severe stenosis. The CT images showed L4/L5 lumbar spinal stenosis and calcified lumbar disc herniation (Fig. 2). The locations of stenosis were classified as central canal, lateral recess, and foraminal narrowing of the spine. Dynamic X-ray images were used to examine spinal instability or backward slippage of the vertebral body.

Fig. 1
figure 1

A patient diagnosed with L4/5 spinal stenosis on MRI; (a) Sagittal view demonstrates spinal stenosis at the L4/L5 level (b) Transverse views of spinal stenosis and lateral recess stenosis

Fig. 2
figure 2

CT image showed (a) L4/L5 lumbar spinal stenosis and calcified lumbar disc herniation (b) Lumbar foraminoplasty (left) and decompression with removal of the calcified lumbar disc herniation (indicated by red arrows)

Surgical method (L4/L5)

Patients were placed in the prone position with the lumbar spine in mild flexion on a radiolucent table, and a C-arm fluoroscopy machine was used. The entry point of the needle was selected at a distance of 8–12 cm from the midline and was situated just above the facet joint on the lateral view. After local anesthesia, a puncture needle (18 gauge) was inserted by a posterolateral approach with a lateral view. After infiltrating 15–20 mL of 0.5% lidocaine in the intervertebral foramen, the needle was replaced with a 1-mm-diameter guidewire. Then a 22-gauge needle was inserted into the disc, followed by the injection of contrast medium (9 ml of iohexol with 1 ml of methylene blue) into the disc. A blunt tapered cannulated obturator was passed over the guide wire under fluoroscopic guidance. Sequential protective cannulas were introduced over the obturator until the final protective cannula was placed in the proper position. Foraminoplasty was performed using a 10-mm-diameter trephine via the transforaminal approach. After that, the protective cannula was replaced with an 8-mm working cannula. The endoscope (SPINENDOS GmbH, Munich, Germany) was positioned through a working casing pipe that was inserted through an 8-mm skin incision centered on a guidewire. The prominent intervertebral disc was stained using methylene blue and then removed by using a pituitary rongeur under endoscope. Next, the hypertrophied ligamentum flavum, facet joints, and anterior herniated disc were resected to achieve decompression. Epidural bleeding was controlled with a radiofrequency probe (SPINENDOS GmbH, Munich, Germany) under saline irrigation. Lastly, the working cannula and the endoscope were removed and the skin was sutured.

Outcome measurement

Clinical outcomes were evaluated using the Visual Analog Scale (VAS; ranging from 0 to 10) to score pain [11] and the Oswestry Disability Index (ODI; ranging from 0% to 100% with higher scores meaning more severe disability) [12] preoperatively and postoperatively at 1 week, 3 months, and 1 year. The clinical variables include preoperative comorbidities, operation time, type of spinal stenosis, stenosis grade, spinal instability, and level of decompressed disc. Spinal instability was defined as greater than 3 mm translational motion and greater than 10 degrees angular motion (between L1 and L5) and greater than 4 mm translational motion and greater than 20 degrees angular motion (at L5/S1) [13].

Statistical analysis

Data are expressed as the mean ± standard deviation for continuous variables. The Friedman test was performed to make comparisons of pain changes over time after percutaneous transforaminal endoscopic decompression. For spinal stenosis type and severity of stenosis, the improvement percentage of ODI and VAS scores were compared using the independent-samples Kruskal-Wallis test. The Mann-Whitney U test was used to make comparisons of improvement percentages of ODI and VAS scores based on spinal instability status and revision surgery status. A P value < 0.05 was considered to indicate statistical significance, and all tests were two-tailed. All statistical analyses were performed on a personal computer with the statistical package SPSS for Windows (Version 16.0, Chicago, IL, USA).

Results

Demographic characteristics and clinical data of all patients are presented in Table 1. The patients consisted of 20 men and 25 women, ranging in age from 45 to 82 years (mean age 62 years). There was no statistically significant difference between the two groups with respect to age, BMI, spinal instability, the type of spinal stenosis, recurrent stenosis, and preoperative VAS and ODI scores. The rate of transient dysesthesia was 4.4% in the PTED group. Regarding the types of spinal stenosis, the most common type was lateral recess stenosis (n = 22), followed by central stenosis (n = 13) and foraminal stenosis (n = 10). Most patients had a moderate stenosis grade (n = 19). All patients had one-level (L3/4, n = 5; L4/5, n = 23; L5/S1, n = 17) lumbar spinal stenosis. Regarding comparisons of VAS-back, VAS-leg, and ODI scores before and after operation, VAS and ODI scores significantly improved. The preoperative VAS score for low back pain was 6.70 ± 1.15, while postoperative 1-week, 3-month, and 1-year VAS scores for low back pain were 3.07 ± 1.09, 2.90 ± 1.13 and 2.58 ± 1.11, respectively (P  <  0.001). The preoperative VAS-leg score was 7.01 ± 0.84, while VAS-leg scores for postoperative 1 week, 3 months and 1 year were 2.63 ± 1.23, 2.44 ± 1.33 and 2.28 ± 1.33, respectively (P  <  0.001). The preoperative ODI score was 46.18 ± 10.11, while postoperative ODI scores for 1 week, 3 months and 1 year were 19.29 ± 9.63, 16.31 ± 9.87 and 14.40 ± 9.59, respectively (P  <  0.001) (Table 2). Regarding types of spinal stenosis, there were no significant differences according to the improvements of ODI and VAS scores at 1 week, 3 months and 1 year. However, the improvement percentage of leg VAS score was significantly less in patients with severe stenosis at both 3 months and 1 year postoperatively (Table 3).

Table 1 Demographic characteristics and clinical data of 45 patients with lumbar spinal stenosis (LSS)
Table 2 Comparisons of VAS and ODI scores before and after operation in patients with LSS
Table 3 Changes in ODI and VAS scores from baseline according to the type of spinal stenosis and stenosis grade

In terms of changes in ODI and VAS scores from baseline, the improvement percentages of VAS-back and VAS-leg scores were significantly less in patients with spinal instability. Similar results were found in patients who previously had operations in the same segment. Patients who had undergone revision surgery in the same segment had significantly less improvement in ODI postoperatively (Table 4).

Table 4 Changes in ODI and VAS scores from baseline according to spinal instability and revision surgery

Discussion

The results of this study demonstrate that percutaneous transforaminal endoscopic decompression can be an effective treatment for elderly patients with lumbar spondylosis and spinal stenosis. Improvements in ODI and VAS scores were observed. Lumbar stenosis is an aging-related degenerative spine disease. The conservative approach might be the first option in patients with LSS and advanced age. Epidural injection of glucocorticoids plus lidocaine is commonly used in the treatment of LSS. Recently, it has been reported glucocorticoids plus lidocaine offered no short-term or long-term benefits as compared with epidural injection of lidocaine alone in the treatment of LSS [14, 15]. In a combined as-treated analysis, patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated non-surgically. The efficacy of surgery for spinal stenosis has been reported in a randomized cohort controlled trial [16]. The surgical complication rates of open laminectomy for patients with LSS were from 4.8 to 8.8% [17, 18]. Because of such high surgical complication rates, endoscopic techniques such as PTED are preferred by most surgeons when treating patients who have high risks of side effects from general anesthesia. Currently, successful clinical outcomes have been achieved in LSS patients treated with full-endoscopic decompression for the defined indications [19]. Endoscopic approaches have also been widely performed for elderly patients with soft disc herniation and spinal stenosis. In a case series study, 85 patients having lumbar lateral recess stenosis with or without combined herniated discs were treated with percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar discectomy (PLF-PELD) and 90.6% of them reported the outcome as satisfactory [20]. However, some difficulty with full-endoscopic operations have been reported, such as incomplete removal of disc fragments, a steep learning curve, and recurrence [21]. The rate of incomplete removal of a herniated disc was 2.8 (283/10,288) in patients treated with PELD [22]. The recurrence rates following full-endoscopic operation for a herniated disc were from 5 to 6.2% [23, 24]. Elderly patients (age ≥ 60 years) and patients with diabetes had a higher risk of surgical failure during a full-endoscopic operation [25]. A modified PLF-PELD technique for patients with complex uncontained lumbar herniated discs has been reported, and 3.7% (5/134) of patients treated with it had recurrent herniation at the same level [26]. In the present study, we found that LSS patients treated with percutaneous transforaminal endoscopic decompression were satisfied with clinical outcomes regarding the improvement of ODI and VAS scores. However, a similar result was not found for LSS patients with lumbar instability. Fusion surgery is reserved for patients with coexisting instability; however, an increasing trend of fusion surgery between 2004 and 2009 was reported in a nationwide study [27]. The rate of fusions for LSS patients without degenerative instability increased from 13.5 to 21.4%, whereas the rate of decompressions alone decreased from 67.2 to 59.1%. Treatments of decompression with concomitant fusion for LSS patients have been reported. However, it has been argued whether decompression alone or decompression with concomitant fusion leads to better results for LSS patients [28]. The efficacy of decompression with concomitant fusion for LSS is unclear. Although minimally invasive lumbar interbody fusion surgery with percutaneous pedicle screw fixation, decompression of the spinal canal and intervertebral fusion under the dilatation channel relatively protect the paravertebral muscles and facet joints of the lumbar spine, adjacent segment disc degeneration problems remain [29]. A meta-analysis study revealed that additional fusion in the management of LSS yielded no clinical improvements over decompression alone [30]. A similar result was found in the management of degenerative LSS. Radiological investigations and patient-reported outcomes have been used to assess the efficacy of surgery for spinal disorders. Fusion has been associated with reduced disc space height at the adjacent segment and increased adjacent segment degeneration, but it had no influence on patient self-rated outcomes as well as VAS and ODI scores [31]. Due to inconsistent outcomes of reported studies, it is difficult to conclude an appropriate surgical approach for the treatment of LSS patients with spinal instability. Decompression alone cannot effectively improve the problem of subsidence of the intervertebral space and lumbar instability; therefore, LSS patients with lumbar instability tend to have poor postoperative results [6]. In the current study, we found that LSS patients with lumbar instability who underwent percutaneous transforaminal endoscopic decompression could immediately experience pain relief but had less improvement at 3 months postoperatively compared to LSS patients without lumbar instability. Similar results were found in those who had reoperations in the same segment as well.

Limitations

The present study also has some limitations. Due to it being a retrospective study, a proper control group is lacking. Besides, all surgeries were performed by a single neurosurgeon and the improvement in surgical performance over time has not been evaluated. Also, the data were collected at a single medical center in China, which may somewhat limit the applicability of the study’s results. Larger scale studies are required to further verify the findings of the present study.

Conclusions

The PTED approach seems to give good results for the treatment of LSS. However, this approach may be less effective for LSS patients who have lumbar instability or require revision surgery in the same segment.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ODI:

Oswestry disability index

VAS:

Visual analog scale

CT:

Computed tomography

MRI:

Magnetic resonance imaging

LSS:

lumbar spinal stenosis

References

  1. Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010;24(2):253–65.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Ahn Y. Percutaneous endoscopic decompression for lumbar spinal stenosis. Expert Rev Med Devices. 2014;11(6):605–16.

    Article  CAS  PubMed  Google Scholar 

  3. Kim JH, Kim HS, Kapoor A, Adsul N, Kim KJ, Choi SH, Jang JS, Jang IT, Oh SH. Feasibility of full endoscopic spine surgery in patients over the age of 70 years with degenerative lumbar spine disease. Neurospine. 2018;15(2):131–7.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Zhou YL, Chen G, Bi DC, Chen X. Short-term clinical efficacy of percutaneous transforaminal endoscopic discectomy in treating young patients with lumbar disc herniation. J Orthop Surg Res. 2018;13(1):61.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Wong AP, Smith ZA, Lall RR, Bresnahan LE, Fessler RG. The microendoscopic decompression of lumbar stenosis: a review of the current literature and clinical results. Minim Invasive Surg. 2012;2012:325095.

    PubMed  PubMed Central  Google Scholar 

  6. Wen B, Zhang X, Zhang L, Huang P, Zheng G. Percutaneous endoscopic transforaminal lumbar spinal canal decompression for lumbar spinal stenosis. Medicine (Baltimore). 2016;95(50):e5186.

    Article  Google Scholar 

  7. Singh R, Zeng Xin G, Hirachan MP, Yu Cheng L. Outcome of percutaneous Transforaminal endoscopic lumbar surgery in >60-year-old patients with low Back pain. Asian Spine J. 2018;12(3):511–7.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Liu X, Yuan S, Tian Y, Wang L, Gong L, Zheng Y, Li J. Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopic discectomy, and microdiscectomy for symptomatic lumbar disc herniation: minimum 2-year follow-up results. J Neurosurg Spine. 2018;28(3):317–25.

    Article  PubMed  Google Scholar 

  9. Wu WJ, Liang Y, Zhang XK, Cao P, Zheng T. Complications and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion for the treatment of one- or two-level degenerative disc diseases of the lumbar spine in patients older than 65 years. Chin Med J. 2012;125(14):2505–10.

    PubMed  Google Scholar 

  10. Schizas C, Theumann N, Burn A, Tansey R, Wardlaw D, Smith FW, Kulik G. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976). 2010;35(21):1919–24.

    Article  Google Scholar 

  11. Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006;15(Suppl 1):S17–24.

    Article  PubMed  Google Scholar 

  12. Lue YJ, Hsieh CL, Huang MH, Lin GT, Lu YM. Development of a Chinese version of the Oswestry disability index version 2.1. Spine. 2008;33(21):2354–60.

    Article  PubMed  Google Scholar 

  13. Nachemson A. The role of spine fusion: question 8. Spine. 1981;6(3):306–7.

    Article  Google Scholar 

  14. Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD, Bauer Z, Bresnahan BW, Avins AL, Nedeljkovic SS, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11–21.

    Article  PubMed  Google Scholar 

  15. Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Bauer Z, Avins AL, Nedeljkovic SS, Nerenz DR, Shi XR, et al. Long-term effects of repeated injections of local anesthetic with or without corticosteroid for lumbar spinal stenosis: a randomized trial. Arch Phys Med Rehabil. 2017;98(8):1499–507 e1492.

    Article  PubMed  Google Scholar 

  16. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358(8):794–810.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Hong SW, Choi KY, Ahn Y, Baek OK, Wang JC, Lee SH, Lee HY. A comparison of unilateral and bilateral laminotomies for decompression of L4-L5 spinal stenosis. Spine. 2011;36(3):E172–8.

    Article  PubMed  Google Scholar 

  18. Ruetten S, Komp M, Merk H, Godolias G. Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique: a prospective, randomized, controlled study. J Neurosurg Spine. 2009;10(5):476–85.

    Article  PubMed  Google Scholar 

  19. Lee CH, Choi M, Ryu DS, Choi I, Kim CH, Kim HS, Sohn MJ. Efficacy and safety of full-endoscopic decompression via interlaminar approach for central or lateral recess spinal stenosis of the lumbar spine: A meta-analysis. Spine (Phila Pa 1976). 2018;43(24):1756–64.

  20. Li ZZ, Hou SX, Shang WL, Cao Z, Zhao HL. Percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar decompression for lateral recess stenosis through transforaminal approach: technique notes and 2 years follow-up. Clin Neurol Neurosurg. 2016;143:90–4.

    Article  PubMed  Google Scholar 

  21. Moon ASM, Rajaram Manoharan SR. Endoscopic spine surgery: current state of art and the future perspective. Asian Spine J. 2018;12(1):1–2.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Choi KC, Lee JH, Kim JS, Sabal LA, Lee S, Kim H, Lee SH. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10,228 cases. Neurosurgery. 2015;76(4):372–80 discussion 380-371; quiz 381.

    Article  PubMed  Google Scholar 

  23. Peng CW, Yeo W, Tan SB. Percutaneous endoscopic lumbar discectomy: clinical and quality of life outcomes with a minimum 2 year follow-up. J Orthop Surg Res. 2009;4:20.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Ruetten S, Komp M, Merk H, Godolias G. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976). 2008;33(9):931–9.

    Article  Google Scholar 

  25. Wang H, Zhou Y, Li C, Liu J, Xiang L. Risk factors for failure of single-level percutaneous endoscopic lumbar discectomy. J Neurosurg Spine. 2015;23(3):320–5.

    Article  PubMed  Google Scholar 

  26. Li ZZ, Hou SX, Shang WL, Song KR, Zhao HL. Modified percutaneous lumbar Foraminoplasty and percutaneous endoscopic lumbar discectomy: instrument design, technique notes, and 5 years follow-up. Pain Physician. 2017;20(1):E85–98.

    Article  PubMed  Google Scholar 

  27. Bae HW, Rajaee SS, Kanim LE. Nationwide trends in the surgical management of lumbar spinal stenosis. Spine (Phila Pa 1976). 2013;38(11):916–26.

    Article  Google Scholar 

  28. Dijkerman ML, Overdevest GM, Moojen WA, Vleggeert-Lankamp CLA. Decompression with or without concomitant fusion in lumbar stenosis due to degenerative spondylolisthesis: a systematic review. Eur Spine J. 2018;27(7):1629–43.

    Article  CAS  PubMed  Google Scholar 

  29. Yang Y, Liu B, Rong LM, Chen RQ, Dong JW, Xie PG, Zhang LM, Feng F. Microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative disease: short-term and medium-term outcomes. Int J Clin Exp Med. 2015;8(11):21319–26.

    CAS  PubMed  PubMed Central  Google Scholar 

  30. Chang W, Yuwen P, Zhu Y, Wei N, Feng C, Zhang Y, Chen W. Effectiveness of decompression alone versus decompression plus fusion for lumbar spinal stenosis: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2017;137(5):637–50.

    Article  PubMed  Google Scholar 

  31. Mannion AF, Leivseth G, Brox JI, Fritzell P, Hagg O, Fairbank JC. ISSLS prize winner: long-term follow-up suggests spinal fusion is associated with increased adjacent segment disc degeneration but without influence on clinical outcome: results of a combined follow-up from 4 randomized controlled trials. Spine (Phila Pa 1976). 2014;39(17):1373–83.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

No funding was received.

Author information

Authors and Affiliations

Authors

Contributions

Study conception and design: PX, FF, ZC, LH, C.-M.C., and LR.; study performance: PX, FF, ZC, LH, BY, RC, WW, BL, JD, TS, LZ, and LR.; writing of the manuscript: PX, FF, ZC, and LH.; manuscript review and editing: PX, LH, BY, RC, WW, BL, JD, TS, LZ, C.-M.C., and LR.; study supervision: C.-M.C. and LR. All authors have read and approved the final version of the manuscript.

Corresponding authors

Correspondence to Chien-Min Chen or Limin Rong.

Ethics declarations

Ethics approval

The study was reviewed and approved by the Ethics Committee of the Third Affiliated Hospital of Sun Yat-Sen University.

Consent for publication

Not applicable.

Competing interests

None of the authors have any competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Xie, P., Feng, F., Chen, Z. et al. Percutaneous transforaminal full endoscopic decompression for the treatment of lumbar spinal stenosis. BMC Musculoskelet Disord 21, 546 (2020). https://doi.org/10.1186/s12891-020-03566-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12891-020-03566-x

Keywords