Short-term effectiveness of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Bin ^1,2 ,  KONG Qingquan ^1,2 , YANG Jing ¹ , FENG Pin ² , MA Junsong ² , LIU Junlin ²

1. Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;
2. Department of Orthopedics, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region, Chengdu Sichuan, 610041, P.R.China;

Corresponding?author：

KONG Qingquan, Email: kqqspine@126.com

Keywords：

Lumbar central spinal stenosis; spinal decompression; percutaneous endoscopy; transforaminal approach

DOI：

10.7507/1002-1892.201904131

Video：

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Objective To observe the effectiveness and safety of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis.Methods A retrospective analysis of 44 patients with single-segment severe central lumbar spinal stenosis with bilateral lower extremity symptoms between October 2015 and December 2017 was performed. Among them, 36 cases underwent bilateral decompression through bilateral transforaminal approach, and 8 cases underwent bilateral decompression through unilateral transforaminal approach. There were 25 males and 19 females, the age ranged from 56 to 89 years with an average of 68.6 years. The disease duration was 5-39 months with an average of 14.5 months. Involved segments: L_{3, 4} in 6 cases, L_{4, 5} in 33 cases, and L₅, S₁ in 5 cases. The dural sac cross-sectional area (DSCA) of the MRI was (66.36±8.48) mm². Morphological grading (MG) classification: 29 cases of grade C, 15 cases of grade D. The visual analogue scale (VAS) score of preoperative low back pain was 2.3±1.0 and the VAS score of lower extremity pain was 7.8±1.2; the Oswestry disability index (ODI) was 77.8±7.3. Postoperative VAS scores, ODI scores, MG classification, and DSCA were recorded and compared with preoperative ones, and clinical outcomes were assessed by using the modified MacNab criteria.Results All patients successfully underwent surgery and the wounds healed by first intention. All 44 patients were followed up 13-46 months with an average of 24.8 months. One patient developed postoperative lower extremity paralysis and 1 patient developed a dural tear. There was no infection, recurrence, or revision surgery during the follow-up. Postoperative imaging showed that the central spinal canal was enlarged and the area of the dural sac was significantly increased compared with preoperative one. The VAS score of low back pain was 2.4±0.6 and 2.5±0.8 at 1 month after operation and at last follow-up, showing no significant difference when compared with preoperative scores (P>0.05). The VAS of lower limb pain was 2.1±0.6 and 2.0±1.1 at 1 month after operation and at last follow-up, which was significantly improved when compared with preoperative scores (P<0.05); but no significant difference was found between at 1 month after operation and at last follow-up (P>0.05). At last follow-up, the ODI score was 19.7±6.4, and the DSCA was (104.93±12.56) mm², which was significantly improved when compared with preoperative values (P<0.05). The MG classification was also significantly higher than preoperative one (Z=?5.789, P=0.000). According to the modified MacNab criteria, the results were excellent in 32 cases, good in 9 cases, and fair in 3 cases, with an excellent and good rate of 93.2%.Conclusion Percutaneous endoscopic transforaminal bilateral decompression for treating severe central lumbar spinal stenosis has the advantages of less trauma, adequate decompression, and rapid recovery. The short-term effectiveness is good.

Citation： ZHANG Bin, KONG Qingquan, YANG Jing, FENG Pin, MA Junsong, LIU Junlin. Short-term effectiveness of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(11): 1399-1405. doi: 10.7507/1002-1892.201904131 Copy

1.	Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med, 2008, 358(8): 818-825.
2.	de Graaf I, Prak A, Bierma-Zeinstra S, et al. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine (Phila Pa 1976), 2006, 31(10): 1168-1176.
3.	Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J, 2013, 13(7): 734-743.
4.	Epstein NE, Maldonado VC, Cusick JF. Symptomatic lumbar spinal stenosis. Surg Neurol, 1998, 50(1): 3-10.
5.	Armon C, Argoff CE, Samuels J, et al. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 2007, 68(10): 723-729.
6.	Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med, 2008, 358(8): 794-810.
7.	Bresnahan LE, Smith JS, Ogden AT, et al. Assessment of paraspinal muscle cross-sectional area after lumbar decompression: minimally invasive versus open approaches. Clin Spine Surg, 2017, 30(3): E162-E168.
8.	梁海峰, 陸順一, 劉書豪, 等. 高齡腰椎管狹窄癥患者的手術方式選擇及療效. 中國脊柱脊髓雜志, 2018, 28(8): 705-712.
9.	Amundsen T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study Spine (Phila Pa 1976), 2000, 25(11): 1424-1435.
10.	L?nne G, ?deg?rd B, Johnsen LG, et al. MRI evaluation of lumbar spinal stenosis: is a rapid visual assessment as good as area measurement? Eur Spine J, 2014, 23(6): 1320-1324.
11.	Ruetten S, Komp M, Merk H, et al. 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): 476-485.
12.	Komp M, Hahn P, Oezdemir S, et al. Bilateral spinal decompression of lumbar central stenosis with the full-endoscopic interlaminar versus microsurgical laminotomy technique: a prospective, randomized, controlled study. Pain Physician, 2015, 18(1): 61-70.
13.	Ahn Y, Lee SH, Park WM, et al. Posterolateral percutaneous endoscopic lumbar foraminotomy for L5-S1 foraminal or lateral exit zone stenosis. Technical note. J Neurosurg, 2003, 99(3 Suppl): 320-323.
14.	Kambin P, Casey K, O'Brien E, et al. Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg, 1996, 84(3): 462-467.
15.	Wang Y, Dou Q, Yang J, et al. Percutaneous endoscopic lumbar decompression for lumbar lateral spinal canal stenosis: classification of lateral region of lumbar spinal canal and surgical approaches. World Neurosurg, 2018, 119: e276-e283.
16.	王玉, 孔清泉, 宋躍明. 精準椎間孔成形減壓術治療腰椎側隱窩狹窄癥的近期療效分析. 中國修復重建外科雜志, 2017, 31(11): 1334-1340.
17.	Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am), 1971, 53(5): 891-903.
18.	腰椎管狹窄癥手術治療規范中國專家共識組. 腰椎管狹窄癥手術治療規范中國專家共識(2014 年). 中華醫學雜志, 2014, 94(35): 2724-2725.
19.	Wen B, Zhang X, Zhang L, et al. Percutaneous endoscopic transforaminal lumbar spinal canal decompression for lumbar spinal stenosis. Medicine (Baltimore), 2016, 95(50): e5186.
20.	Ahn Y. Percutaneous endoscopic decompression for lumbar spinal stenosis. Expert Rev Med Devices, 2014, 11(6): 605-616.
21.	Shin SH, Bae JS, Lee SH, et al. Transforaminal endoscopic decompression for lumbar spinal stenosis: a novel surgical technique and clinical outcomes. World Neurosurg, 2018, 114: e873-e882.
22.	Komp M, Hahn P, Merk H, et al. Bilateral operation of lumbar degenerative central spinal stenosis in fullendoscopic interlaminar technique with unilateral approach. J Spinal Disord Tech, 2011, 24: 281-287.
23.	Hwa Eum J, Hwa Heo D, Son SK, et al. Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine, 2016, 24(4): 602-607.
24.	Torudom Y, Dilokhuttakarn T. Two portal percutaneous endoscopic decompression for lumbar spinal stenosis: preliminary study. Asian Spine J, 2016, 10(2): 335-342.
25.	Lee CW, Yoon KJ, Jun JH. Percutaneous endoscopic laminotomy with flavectomy by uniportal, unilateral approach for the lumbar canal or lateral recess stenosis. World Neurosurg, 2018, 113: e129-e137.
26.	劉印, 蔡鵬, 孔清泉, 等. 全脊柱內窺鏡治療合并椎管內骨化腰椎疾患療效觀察. 中國修復重建外科雜志, 2017, 31(11): 1326-1333.
27.	劉俊麟, 孔清泉. 全脊柱內鏡在骨化類繼發性腰椎管狹窄癥應用中的相關問題述評. 中國骨與關節雜志, 2019, 8(2): 81-87.
28.	徐寶山, 馬信龍, 胡永成. 頸椎和胸椎經皮內鏡手術的并發癥及預防措施. 中華骨科雜志, 2018, 38(16): 1003-1008.

1. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med, 2008, 358(8): 818-825.
2. de Graaf I, Prak A, Bierma-Zeinstra S, et al. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine (Phila Pa 1976), 2006, 31(10): 1168-1176.
3. Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J, 2013, 13(7): 734-743.
4. Epstein NE, Maldonado VC, Cusick JF. Symptomatic lumbar spinal stenosis. Surg Neurol, 1998, 50(1): 3-10.
5. Armon C, Argoff CE, Samuels J, et al. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 2007, 68(10): 723-729.
6. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med, 2008, 358(8): 794-810.
7. Bresnahan LE, Smith JS, Ogden AT, et al. Assessment of paraspinal muscle cross-sectional area after lumbar decompression: minimally invasive versus open approaches. Clin Spine Surg, 2017, 30(3): E162-E168.
8. 梁海峰, 陸順一, 劉書豪, 等. 高齡腰椎管狹窄癥患者的手術方式選擇及療效. 中國脊柱脊髓雜志, 2018, 28(8): 705-712.
9. Amundsen T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study Spine (Phila Pa 1976), 2000, 25(11): 1424-1435.
10. L?nne G, ?deg?rd B, Johnsen LG, et al. MRI evaluation of lumbar spinal stenosis: is a rapid visual assessment as good as area measurement? Eur Spine J, 2014, 23(6): 1320-1324.
11. Ruetten S, Komp M, Merk H, et al. 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): 476-485.
12. Komp M, Hahn P, Oezdemir S, et al. Bilateral spinal decompression of lumbar central stenosis with the full-endoscopic interlaminar versus microsurgical laminotomy technique: a prospective, randomized, controlled study. Pain Physician, 2015, 18(1): 61-70.
13. Ahn Y, Lee SH, Park WM, et al. Posterolateral percutaneous endoscopic lumbar foraminotomy for L5-S1 foraminal or lateral exit zone stenosis. Technical note. J Neurosurg, 2003, 99(3 Suppl): 320-323.
14. Kambin P, Casey K, O'Brien E, et al. Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg, 1996, 84(3): 462-467.
15. Wang Y, Dou Q, Yang J, et al. Percutaneous endoscopic lumbar decompression for lumbar lateral spinal canal stenosis: classification of lateral region of lumbar spinal canal and surgical approaches. World Neurosurg, 2018, 119: e276-e283.
16. 王玉, 孔清泉, 宋躍明. 精準椎間孔成形減壓術治療腰椎側隱窩狹窄癥的近期療效分析. 中國修復重建外科雜志, 2017, 31(11): 1334-1340.
17. Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am), 1971, 53(5): 891-903.
18. 腰椎管狹窄癥手術治療規范中國專家共識組. 腰椎管狹窄癥手術治療規范中國專家共識(2014 年). 中華醫學雜志, 2014, 94(35): 2724-2725.
19. Wen B, Zhang X, Zhang L, et al. Percutaneous endoscopic transforaminal lumbar spinal canal decompression for lumbar spinal stenosis. Medicine (Baltimore), 2016, 95(50): e5186.
20. Ahn Y. Percutaneous endoscopic decompression for lumbar spinal stenosis. Expert Rev Med Devices, 2014, 11(6): 605-616.
21. Shin SH, Bae JS, Lee SH, et al. Transforaminal endoscopic decompression for lumbar spinal stenosis: a novel surgical technique and clinical outcomes. World Neurosurg, 2018, 114: e873-e882.
22. Komp M, Hahn P, Merk H, et al. Bilateral operation of lumbar degenerative central spinal stenosis in fullendoscopic interlaminar technique with unilateral approach. J Spinal Disord Tech, 2011, 24: 281-287.
23. Hwa Eum J, Hwa Heo D, Son SK, et al. Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine, 2016, 24(4): 602-607.
24. Torudom Y, Dilokhuttakarn T. Two portal percutaneous endoscopic decompression for lumbar spinal stenosis: preliminary study. Asian Spine J, 2016, 10(2): 335-342.
25. Lee CW, Yoon KJ, Jun JH. Percutaneous endoscopic laminotomy with flavectomy by uniportal, unilateral approach for the lumbar canal or lateral recess stenosis. World Neurosurg, 2018, 113: e129-e137.
26. 劉印, 蔡鵬, 孔清泉, 等. 全脊柱內窺鏡治療合并椎管內骨化腰椎疾患療效觀察. 中國修復重建外科雜志, 2017, 31(11): 1326-1333.
27. 劉俊麟, 孔清泉. 全脊柱內鏡在骨化類繼發性腰椎管狹窄癥應用中的相關問題述評. 中國骨與關節雜志, 2019, 8(2): 81-87.
28. 徐寶山, 馬信龍, 胡永成. 頸椎和胸椎經皮內鏡手術的并發癥及預防措施. 中華骨科雜志, 2018, 38(16): 1003-1008.

Chinese Journal of Reparative and Reconstructive Surgery

Short-term effectiveness of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis

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