Percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for lumbar spinal stenosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

XIN Zhijun , CAI Menghan ^△ , JI Wenjun , CHEN Lin , KONG Weijun , LI Jin , QIN Jianpu , WANG Ansu , AO Jun ,  LIAO Wenbo

Department of Spinal Surgery, Affiliated Hospital of Zunyi Medical Univerty, Zunyi Guizhou, 563003, P.R.China;

Corresponding author：

LIAO Wenbo, Email: wenbo900@sina.com

Keywords：

Lumbar spinal stenosis; full spinal endoscope; unilateral approach; bilateral decompression; minimally invasive spinal surgery

DOI：

10.7507/1002-1892.201904005

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Objective To design the surgical strategy of percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral lumbar spinal stenosis (LSS) and to evaluate the effectiveness. Methods The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral LSS was designed according to the pathological features of LSS. The technique was used to treat 42 patients with LSS between January 2016 and January 2018. There were 18 males and 24 females with an average age of 61.7 years (range, 46-81 years). The duration of symptoms was 1-20 years, with an average of 9.7 years. The surgical segment at L_{4, 5} were 27 cases, at L₅, S₁ were 15 cases. The operation time and perioperative complications were recorded. Lumbar X-ray, CT, and MRI examinations were performed at 1 week, 3 months, and 1 year after operation. Visual analogue scale (VAS) score was used to evaluate the low back pain and leg pain, Oswestry disability index (ODI) was used to evaluate the lumbar function, and single continuous walking distance (SCWD) was used to evaluate lower extremity nerve function. The clinical efficacy was evaluated by MacNab criteria at 1 year after operation. Results All patients underwent surgery successfully. The operation time was 68-141 minutes with an average of 98.2 minutes. All 42 patients were followed up 12-24 months with an average of 18.8 months. There were 2 cases of dural tears during operation, and 1 case of transient dysfunction of the lower limbs of the decompression channel after operation. All of them were cured after corresponding treatment. No serious complications such as death, major bleeding, or irreversible nerve injury occurred during follow-up. No segmental instability was found according to postoperative lumbar hyperextension and flexion X-ray films, and postoperative CT and MRI imaging showed that the stenotic lumbar spinal canal was significantly enlarged, and the compression of the nerve root was sufficient. The VAS score of low back pain and leg pain, ODI score, and SCWD at each time point after operation were significantly improved when compared with those before operation (P<0.05); the indexes were significantly improved over time after operation, and the differences were significantly (P<0.05). The clinical efficacy was evaluated by MacNab standard at 1 year after operation, and the results were excellent in 18 cases, good in 20 cases, fair in 3 cases, and poor in 1 case. The excellent and good rate was 90.5%. Conclusion The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for LSS is a safe and effective procedure. A well-designed surgical strategy and mastery of its technical points are important guarantees for successful operation and satisfactory results.

Citation： XIN Zhijun, CAI Menghan, JI Wenjun, CHEN Lin, KONG Weijun, LI Jin, QIN Jianpu, WANG Ansu, AO Jun, LIAO Wenbo. Percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for lumbar spinal stenosis. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(7): 822-830. doi: 10.7507/1002-1892.201904005 Copy

1.	廖烨晖, 叶入裴, 唐强, 等. 超声骨刀单侧开窗双侧减压后路腰椎椎体间融合术治疗退变性腰椎管狭窄症. 中国修复重建外科杂志, 2019, 33(4): 416-422.
2.	Aizawa T, Kokubun S, Ozawa H, et al. Increasing incidence of degenerative spinal diseases in Japan during 25 years: the registration system of spinal surgery in Tohoku University Spine Society. Tohoku J Exp Med, 2016, 238(2): 153-163.
3.	Mobbs RJ, Li J, Sivabalan P, et al. Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article. J Neurosurg Spine, 2014, 21(2): 179-186.
4.	Feeney R. Lumbar spinal stenosis. Journal of Pain & Palliative Care Pharmacotherapy, 2016, 30(2): 69.
5.	商振国, 李永民, 张纪威, 等. 保留腰椎后柱结构的改良椎管成形术治疗腰椎管狭窄症的临床研究. 中国修复重建外科杂志, 2016, 30(6): 721-725.
6.	Heo DH, Quillo-Olvera J, Park CK. Can percutaneous biportal endoscopic surgery achieve enough canal decompression for degenerative lumbar stenosis? Prospective Case-Control Study World Neurosurg, 2018, 120: e684-e689.
7.	Storzer B, Schnake KJ. Microscopic bilateral decompression by unilateral approach in spinal stenosis. Eur Spine J, 2016, 25(Suppl 2): 270-271.
8.	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.
9.	Shamji MF, Mroz T, Hsu W, et al. Management of degenerative lumbar spinal stenosis in the elderly. Neurosurgery, 2015, 77(Suppl 4): S68-S74.
10.	Altun I, Yüksel KZ. Histopathological analysis of ligamentum flavum in lumbar spinal stenosis and disc herniation. Asian Spine J, 2017, 11(1): 71-74.
11.	Song H, Hu W, Liu Z, et al. Percutaneous endoscopic interlaminar discectomy of L₅-S₁ disc herniation: a comparison between intermittent endoscopy technique and full endoscopy technique. J Orthop Surg Res, 2017, 12(1): 162.
12.	Choi G, Kim JS, Lokhande P, et al. Percutaneous endoscopic lumbar discectomy by transiliac approach: a case report. Spine (Phila Pa 1976), 2009, 34(12): E443-E446.
13.	Siepe CJ, Sauer D, Michael Mayer H. Full endoscopic, bilateral over-the-top decompression for lumbar spinal stenosis. Eur Spine J, 2018, 27(Suppl 4): 563-565.
14.	Sidon E, Shemesh SS, Mor-Yossef Moldovan L, et al. Molecular profile of ultrastructure changes of the ligamentum flavum related to lumbar spinal canal stenosis. J Cell Biochem, 2019.
15.	Chapman CR, Casey KL, Dubner R, et al. Pain measurement: an overview. Pain, 1985, 22(1): 1-31.
16.	Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
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.	Yabuki S, Fukumori N, Takegami M, et al. Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci, 2013, 18(6): 893-900.
19.	Torudom Y, Dilokhuttakarn T. Two portal percutaneous endoscopic decompression for lumbar spinal stenosis: preliminary study. Asian Spine J, 2016, 10(2): 335-342.
20.	Dechsupa S, Yingsakmongkol W, Limthongkul W, et al. Relative telomere length and oxidative DNA damage in hypertrophic ligamentum flavum of lumbar spinal stenosis. PeerJ, 2018, 6: e5381.
21.	Choi DJ, Kim JE. Efficacy of biportal endoscopic spine surgery for lumbar spinal stenosis. Clin Orthop Surg, 2019, 11(1): 82-88.
22.	Kim JE, Choi DJ. Unilateral biportal endoscopic decompression by 30° endoscopy in lumbar spinal stenosis: Technical note and preliminary report. J Orthop, 2018, 15(2): 366-371.
23.	Yang JC, Kim SG, Kim TW, et al. Analysis of factors contributing to postoperative spinal instability after lumbar decompression for spinal stenosis. Korean J Spine, 2013, 10(3): 149-154.
24.	Cheng X, Zhang K, Sun X, et al. Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis. Spine J, 2017, 17(8): 1127-1133.
25.	Radcliff K, Curry P, Hilibrand A, et al. Risk for adjacent segment and same segment reoperation after surgery for lumbar stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976), 2013, 38(7): 531-539.
26.	Hu ZJ, Fang XQ, Zhou ZJ, et al. Effect and possible mechanism of muscle-splitting approach on multifidus muscle injury and atrophy after posterior lumbar spine surgery. J Bone Joint Surg (Am), 2013, 95(24): e192-e191.
27.	Huang YH, Ou CY. Significant blood loss in lumbar fusion surgery for degenerative spine. World Neurosurg, 2015, 84(3): 780-785.
28.	于庆帅, 陈亮, 晏铮剑, 等. 经皮脊柱内镜治疗经皮椎体成形术后骨水泥椎管内渗漏的疗效观察. 中国修复重建外科杂志, 2017, 31(6): 690-695.
29.	王鹏, 廖文波. 经皮后路全内镜神经根管切开治疗骨性颈神经根管狭窄的手术设计及临床应用. 中国修复重建外科杂志, 2018, 32(5): 536-541.
30.	Ahn Y. Percutaneous endoscopic decompression for lumbar spinal stenosis. Expert Rev Med Devices, 2014, 11(6): 605-616.
31.	Yeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art. Mt Sinai J Med, 2000, 67(4): 327-332.
32.	Hoogland T, Schubert M, Miklitz B, et al. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976), 2006, 31(24): E890-E897.
33.	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.
34.	赵一民, 汤玮, 王振东, 等. 经皮椎间孔镜技术治疗腰椎管狭窄症的早期临床疗效分析. 中国矫形外科杂志, 2016, 24(19): 1745-1748.
35.	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.
36.	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.
37.	Chen J, Jing X, Li C, et al. Percutaneous endoscopic lumbar discectomy for L₅S₁ lumbar disc herniation using a transforaminal approach versus an interlaminar approach: a systematic review and Meta-analysis. World Neurosurg, 2018, 116: 412-420.
38.	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.
39.	Cho JY, Lee SH, Lee HY. Prevention of development of postoperative dysesthesia in transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation: floating retraction technique. Minim Invasive Neurosurg, 2011, 54(5-6): 214-218.

1. 廖烨晖, 叶入裴, 唐强, 等. 超声骨刀单侧开窗双侧减压后路腰椎椎体间融合术治疗退变性腰椎管狭窄症. 中国修复重建外科杂志, 2019, 33(4): 416-422.
2. Aizawa T, Kokubun S, Ozawa H, et al. Increasing incidence of degenerative spinal diseases in Japan during 25 years: the registration system of spinal surgery in Tohoku University Spine Society. Tohoku J Exp Med, 2016, 238(2): 153-163.
3. Mobbs RJ, Li J, Sivabalan P, et al. Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article. J Neurosurg Spine, 2014, 21(2): 179-186.
4. Feeney R. Lumbar spinal stenosis. Journal of Pain & Palliative Care Pharmacotherapy, 2016, 30(2): 69.
5. 商振国, 李永民, 张纪威, 等. 保留腰椎后柱结构的改良椎管成形术治疗腰椎管狭窄症的临床研究. 中国修复重建外科杂志, 2016, 30(6): 721-725.
6. Heo DH, Quillo-Olvera J, Park CK. Can percutaneous biportal endoscopic surgery achieve enough canal decompression for degenerative lumbar stenosis? Prospective Case-Control Study World Neurosurg, 2018, 120: e684-e689.
7. Storzer B, Schnake KJ. Microscopic bilateral decompression by unilateral approach in spinal stenosis. Eur Spine J, 2016, 25(Suppl 2): 270-271.
8. 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.
9. Shamji MF, Mroz T, Hsu W, et al. Management of degenerative lumbar spinal stenosis in the elderly. Neurosurgery, 2015, 77(Suppl 4): S68-S74.
10. Altun I, Yüksel KZ. Histopathological analysis of ligamentum flavum in lumbar spinal stenosis and disc herniation. Asian Spine J, 2017, 11(1): 71-74.
11. Song H, Hu W, Liu Z, et al. Percutaneous endoscopic interlaminar discectomy of L₅-S₁ disc herniation: a comparison between intermittent endoscopy technique and full endoscopy technique. J Orthop Surg Res, 2017, 12(1): 162.
12. Choi G, Kim JS, Lokhande P, et al. Percutaneous endoscopic lumbar discectomy by transiliac approach: a case report. Spine (Phila Pa 1976), 2009, 34(12): E443-E446.
13. Siepe CJ, Sauer D, Michael Mayer H. Full endoscopic, bilateral over-the-top decompression for lumbar spinal stenosis. Eur Spine J, 2018, 27(Suppl 4): 563-565.
14. Sidon E, Shemesh SS, Mor-Yossef Moldovan L, et al. Molecular profile of ultrastructure changes of the ligamentum flavum related to lumbar spinal canal stenosis. J Cell Biochem, 2019.
15. Chapman CR, Casey KL, Dubner R, et al. Pain measurement: an overview. Pain, 1985, 22(1): 1-31.
16. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
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. Yabuki S, Fukumori N, Takegami M, et al. Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci, 2013, 18(6): 893-900.
19. Torudom Y, Dilokhuttakarn T. Two portal percutaneous endoscopic decompression for lumbar spinal stenosis: preliminary study. Asian Spine J, 2016, 10(2): 335-342.
20. Dechsupa S, Yingsakmongkol W, Limthongkul W, et al. Relative telomere length and oxidative DNA damage in hypertrophic ligamentum flavum of lumbar spinal stenosis. PeerJ, 2018, 6: e5381.
21. Choi DJ, Kim JE. Efficacy of biportal endoscopic spine surgery for lumbar spinal stenosis. Clin Orthop Surg, 2019, 11(1): 82-88.
22. Kim JE, Choi DJ. Unilateral biportal endoscopic decompression by 30° endoscopy in lumbar spinal stenosis: Technical note and preliminary report. J Orthop, 2018, 15(2): 366-371.
23. Yang JC, Kim SG, Kim TW, et al. Analysis of factors contributing to postoperative spinal instability after lumbar decompression for spinal stenosis. Korean J Spine, 2013, 10(3): 149-154.
24. Cheng X, Zhang K, Sun X, et al. Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis. Spine J, 2017, 17(8): 1127-1133.
25. Radcliff K, Curry P, Hilibrand A, et al. Risk for adjacent segment and same segment reoperation after surgery for lumbar stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976), 2013, 38(7): 531-539.
26. Hu ZJ, Fang XQ, Zhou ZJ, et al. Effect and possible mechanism of muscle-splitting approach on multifidus muscle injury and atrophy after posterior lumbar spine surgery. J Bone Joint Surg (Am), 2013, 95(24): e192-e191.
27. Huang YH, Ou CY. Significant blood loss in lumbar fusion surgery for degenerative spine. World Neurosurg, 2015, 84(3): 780-785.
28. 于庆帅, 陈亮, 晏铮剑, 等. 经皮脊柱内镜治疗经皮椎体成形术后骨水泥椎管内渗漏的疗效观察. 中国修复重建外科杂志, 2017, 31(6): 690-695.
29. 王鹏, 廖文波. 经皮后路全内镜神经根管切开治疗骨性颈神经根管狭窄的手术设计及临床应用. 中国修复重建外科杂志, 2018, 32(5): 536-541.
30. Ahn Y. Percutaneous endoscopic decompression for lumbar spinal stenosis. Expert Rev Med Devices, 2014, 11(6): 605-616.
31. Yeung AT. The evolution of percutaneous spinal endoscopy and discectomy: state of the art. Mt Sinai J Med, 2000, 67(4): 327-332.
32. Hoogland T, Schubert M, Miklitz B, et al. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976), 2006, 31(24): E890-E897.
33. 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.
34. 赵一民, 汤玮, 王振东, 等. 经皮椎间孔镜技术治疗腰椎管狭窄症的早期临床疗效分析. 中国矫形外科杂志, 2016, 24(19): 1745-1748.
35. 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.
36. 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.
37. Chen J, Jing X, Li C, et al. Percutaneous endoscopic lumbar discectomy for L₅S₁ lumbar disc herniation using a transforaminal approach versus an interlaminar approach: a systematic review and Meta-analysis. World Neurosurg, 2018, 116: 412-420.
38. 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.
39. Cho JY, Lee SH, Lee HY. Prevention of development of postoperative dysesthesia in transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation: floating retraction technique. Minim Invasive Neurosurg, 2011, 54(5-6): 214-218.

Chinese Journal of Reparative and Reconstructive Surgery

Percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for lumbar spinal stenosis

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