Name: Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis (Video) | JoVE Journal
Uploaded: 2023-02-24T13:55:00.000+00:00
Duration: 2 min 2 s
Description: Learn full-endoscopic spinal decompression techniques for lateral recess stenosis using specialized instruments like rongeurs, punches, and oval burs. This minimally invasive approach improves surgical outcomes.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

There is no funding source for this study.

The study protocol was approved by the institutional review board of the Istanbul Faculty of Medicine.
1. Preoperative procedures
<ol>
	<li>Perform the surgeries under general anesthesia. Set the endoscopic and optic instruments, and C-arm devices in the operation room.</li>
	<li>Ensure that the following tools are available for the procedure: dilator, working sleeve, endoscope with a 20&#176; viewing angle and 177 mm in length with a 9.3 mm diameter oval shaft with a 5.6 mm diameter working channel, Kerrison punch (5.5 mm), rongeur (3-4 mm), punch (3-5.4 mm), tip control radioablator probe that applies the radiofrequency current of 4 MHz, fluid control irrigation and suction pump device, 5.5 mm oval burr with lateral protection, burr round, and the diamond round.</li>
</ol>
2. Surgical technique
<ol>
	<li>Place the patient in a prone position with thorax and pelvis support pillows. Flex the hip and the knee at the adjustable operation table to provide a wider interlaminar window. While the surgery can be performed by one surgeon, an assistant would ease the procedure.</li>
	<li>Obtain an anteroposterior (AP) X-ray view to mark the L4-5 interlaminar window near the midline on the ipsilateral side. Ensure that the entry point is close to the midline to enable lateral access below the zygapophyseal joints. 
	NOTE: The C-arm is a device that can rotate 360&#176; around the patient and obtain AP and lateral X-ray views intraoperatively.</li>
	<li>Make a 1 cm incision with a #20 blade until the fascia of the paraspinal muscle is passed. Insert the dilator till it touches the facet joint. Acquire AP and lateral X-ray views to confirm the location of the dilator. 
	NOTE: The dilator is inserted toward the facet joint so that it does not pass through the interlaminar window and injure the neural structures.</li>
	<li>Introduce the working sleeve over the dilator with an oblique opening showing the medial side. Acquire the lateral X-ray view again, confirming the position of the working sleeve. Then, remove the dilator.</li>
	<li>Introduce the endoscope through the working sleeve. Perform the remaining procedure under continuous irrigation with isotonic saline to the operation field.</li>
	<li>After access has been achieved, remove the soft tissues-mainly the paraspinal muscles-using the rongeur. Expose the bony structures of the facet and the ligamentum flavum. Remove the superficial layer of the ligamentum flavum with a 5.4 mm punch for total exposure of the descending facet.</li>
	<li>Begin the bone removal from the medial side of the descending facet from its inferior tip, using the 5.5 mm oval burr with lateral protection to expose the ascending facet.</li>
	<li>Then, expose the ascending facet and its superior tip. The synovial joint is disrupted in this stage, and the ascending facet cartilage can be appreciated. Visualize the deeper layer of the ligamentum flavum here, attaching to the medial side of the ascending facet.</li>
	<li>Use the oval burr with lateral protection again for thinning the ascending facet so that the total removal can be achieved by the Kerrison punch. Use the Kerrison punch for further bone removal toward the lateral.</li>
	<li>The extent of the resection is recommended to reach from the tip of the ascending facet to the middle of the caudal pedicle. Then, resect the ligamentum flavum using the punch from the midline toward the lateral.</li>
	<li>Ensure that the removal of the ligamentum flavum is medial to lateral and cranial to caudal to completely visualize the below lateral recess. Doing this otherwise would risk a dural tear, since the dura is more prominent in the midline.</li>
	<li>While resecting the ligamentum flavum, use the long side of the working sleeve to achieve some tension in the ligament. This way, the dura will separate from the ligament, and the ligament resection will be safer.</li>
	<li>Remove the epidural fat tissue with caution, using the rongeur, until adequate exposure to the neural structures is obtained. After caudal removal of the ligamentum flavum, remove the superior border of the caudal lamina using the Kerrison punch.</li>
	<li>Here, we expect to see the axilla of the nerve root. Mobilize the nerve root medially using the dissector to relieve it from any adhesions. If there is a discopathy contributing to the lateral recess stenosis, address it.</li>
	<li>Medialize the nerve root using the dissector, or turn the long side of the working sleeve. If there is a sequestrated or extruded material, remove it using the rongeur directly from an existing annulus defect. If there is a subligamentous protruding material, use the punch to open the posterior longitudinal ligament and the annulus fibrosis. In that case, evacuate the disc space by using the rongeur (Video 1).</li>
	<li>Coagulate the soft tissues using the radioablator. Here, obtain a lateral X-ray view to understand if the end plates are parallel and how deep it has proceeded. Establish the decompression by resecting parts of the medial descending and ascending facet, the cranial and caudal lamina, and the ligamentum flavum.</li>
	<li>Sufficient decompression of the neural structures can be appreciated. Achieve decompression by resecting half of the pedicle and the ligamentum flavum at the lateral recess.</li>
	<li>After achieving hemostasis using the radioablator, complete the procedure by removing the endoscopic system. Close the wound with a single suture without any drainage.</li>
</ol>
3. Postoperative procedures and follow-up
<ol>
	<li>The hospital stay is short. Mobilize the patients on the same day as the procedure.</li>
	<li>If there are no further complaints, discharge the patients the next day. 
	NOTE: Postoperative pain is low; thus, no need for extended painkiller use. Nonsteroidal anti-inflammatory drugs are commonly used agents if there is pain at the operation site. Rehabilitation and physical therapy are not necessary.</li>
	<li>Recommend the patients to be admitted to the outpatient clinic in the first and fourth weeks.</li>
</ol>

<ol><li>Lee, C. H., Chung, C. K., Kim, C. H., Kwon, J. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Health+care+burden+of+spinal+diseases+in+the+Republic+of+Korea%3A+analysis+of+a+nationwide+database+from+2012+through+2016%5BTitle%5D)+AND+%22Neurospine%22%5BJournal%5D)">Health care burden of spinal diseases in the Republic of Korea: analysis of a nationwide database from 2012 through 2016.</a> Neurospine. 15 (1), 66-76 (2018).</li>
<li>Cinotti, G., Postacchini, F., Fassari, F., Urso, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Predisposing+factors+in+degenerative+spondylolisthesis.+A+radiographic+and+CT+study%5BTitle%5D)+AND+%22International+Orthopaedics%22%5BJournal%5D)">Predisposing factors in degenerative spondylolisthesis. A radiographic and CT study.</a> International Orthopaedics. 21 (5), 337-342 (1997).</li>
<li>Jinkins, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Acquired+degenerative+changes+of+the+intervertebral+segments+at+and+suprajacent+to+the+lumbosacral+junction%3A+A+radioanatomic+analysis+of+the+nondiscal+structures+of+the+spinal+column+and+perispinal+soft+tissues%5BTitle%5D)+AND+%22European+Journal+of+Radiology%22%5BJournal%5D)">Acquired degenerative changes of the intervertebral segments at and suprajacent to the lumbosacral junction: A radioanatomic analysis of the nondiscal structures of the spinal column and perispinal soft tissues.</a> European Journal of Radiology. 50 (2), 134-158 (2004).</li>
<li>Caputy, A. J., Luessenhop, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+evaluation+of+decompressive+surgery+for+degenerative+lumbar+stenosis%5BTitle%5D)+AND+%22Journal+of+Neurosurgery%22%5BJournal%5D)">Long-term evaluation of decompressive surgery for degenerative lumbar stenosis.</a> Journal of Neurosurgery. 77 (5), 669-676 (1992).</li>
<li>Niosi, C. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+effect+of+dynamic+posterior+stabilization+on+facet+joint+contact+forces%3A+An+in+vitro+investigation%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">The effect of dynamic posterior stabilization on facet joint contact forces: An in vitro investigation.</a> Spine. 33 (1), 19-26 (2008).</li>
<li>Hermansen, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+3+different+minimally+invasive+surgical+techniques+for+lumbar+spinal+stenosis%3A+a+randomized+clinical+trial%5BTitle%5D)+AND+%22JAMA+Network+Open%22%5BJournal%5D)">Comparison of 3 different minimally invasive surgical techniques for lumbar spinal stenosis: a randomized clinical trial.</a> JAMA Network Open. 5 (3), 224291(2022).</li>
<li>Ahn, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+endoscopic+decompression+for+lumbar+spinal+stenosis%5BTitle%5D)+AND+%22Expert+Review+of+Medical+Devices%22%5BJournal%5D)">Percutaneous endoscopic decompression for lumbar spinal stenosis.</a> Expert Review of Medical Devices. 11 (6), 605-616 (2014).</li>
<li>Ruetten, S., Komp, M., Merk, H., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Full-endoscopic+interlaminar+and+transforaminal+lumbar+discectomy+versus+conventional+microsurgical+technique%3A+A+prospective%2C+randomized%2C+controlled+study%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: A prospective, randomized, controlled study.</a> Spine. 33 (9), 931-939 (2008).</li>
<li>Annertz, M., Jonsson, B., Strornqvist, B., Holtas, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((No+relationship+between+epidural+fibrosis+and+sciatica+in+the+lumbar+postdiscectomy+syndrome.+A+study+with+contrast-enhanced+magnetic+resonance+imaging+in+symptomatic+and+asymptomatic+patients%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">No relationship between epidural fibrosis and sciatica in the lumbar postdiscectomy syndrome. A study with contrast-enhanced magnetic resonance imaging in symptomatic and asymptomatic patients.</a> Spine. 20 (4), 449-453 (1995).</li>
<li>Cooper, R. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+role+of+epidural+fibrosis+and+defective+fibrinolysis+in+the+persistence+of+postlaminectomy+back+pain%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">The role of epidural fibrosis and defective fibrinolysis in the persistence of postlaminectomy back pain.</a> Spine. 16 (9), 1044-1048 (1991).</li>
<li>Ruetten, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+full-endoscopic+interlaminar+approach+for+lumbar+disc+herniations%5BTitle%5D)+AND+%22Minimally+Invasive+Spine+Surgery+%28Second+Edition%29%3A+A+Surgical+Manual%22%5BJournal%5D)">The full-endoscopic interlaminar approach for lumbar disc herniations.</a> Minimally Invasive Spine Surgery (Second Edition): A Surgical Manual. , 346-355 (2006).</li>
<li>Ruetten, S., Komp, M., Merk, H., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+new+full-endoscopic+technique+for+cervical+posterior+foraminotomy+in+the+treatment+of+lateral+disc+herniations+using+6.9-mm+endoscopes%3A+prospective+2-year+results+of+87+patients%5BTitle%5D)+AND+%22Minimally+Invasive+Neurosurgery%22%5BJournal%5D)">A new full-endoscopic technique for cervical posterior foraminotomy in the treatment of lateral disc herniations using 6.9-mm endoscopes: prospective 2-year results of 87 patients.</a> Minimally Invasive Neurosurgery. 50 (4), 219-226 (2007).</li>
<li>Ruetten, S., Komp, M., Merk, H., Godolias, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Use+of+newly+developed+instruments+and+endoscopes%3A+full-endoscopic+resection+of+lumbar+disc+herniations+via+the+interlaminar+and+lateral+transforaminal+approach%5BTitle%5D)+AND+%22Journal+of+Neurosurgery.+Spine%22%5BJournal%5D)">Use of newly developed instruments and endoscopes: full-endoscopic resection of lumbar disc herniations via the interlaminar and lateral transforaminal approach.</a> Journal of Neurosurgery. Spine. 6 (6), 521-530 (2007).</li>
<li>Atlas, S. J., Keller, R. B., Wu, Y. A., Deyo, R. A., Singer, D. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+outcomes+of+surgical+and+nonsurgical+management+of+lumbar+spinal+stenosis%3A+8+to+10+year+results+from+the+maine+lumbar+spine+study%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study.</a> Spine. 30 (8), 936-943 (2005).</li>
</ol>

The authors report no conflict of interest concerning the materials or methods used in this study.

Conventional surgeries for lateral recess stenosis decompression include laminectomy and extensive resection of the soft and bony tissues4.&#160;Epidural fibrosis and scarring can be problematic, become symptomatic, and make revision surgery more complex9. Resection of the posterior musculature and the bony elements can cause surgery-induced segmental instability10. This has led to the need for more tissue-sparing surgeries. Technical advances have e...

Spinal stenosis, both central and lateral recess stenosis, is the most common pathology in the elderly population1. Lateral recess stenosis can cause symptoms of neurogenic claudication, radicular pain, and motor and sensory deficits. If present, back pain is usually attributed to accompanying segmental instability2,3.
Numerous surgical procedures have been described to date, some of which are still controversial4. Over the years, the trend has developed from more aggressive to more selective and minimally invasive techniques. In conventional surgery, epidural fibrosis and scarring may become symptomatic, making revision surgery more difficult. It may cause surgery-induced instability due to unnecessary bone removal and tissue damage5,6.
The stenotic zone in lumbar spinal stenosis can be in the central, lateral recess, or intervertebral foramen. The full-endoscopic approach depends on the pathology and the surgeon&#39;s preferences, and can be interlaminar, transforaminal, or extraforaminal7,8. The anatomy of the foramen and the exiting nerve can make the foraminal approaches challenging. Therefore, the interlaminar approach enables better access and understanding of the pathology and the opportunity to decompress. Patient selection is important; patients with ligamentum flavum hypertrophy, facet joint hypertrophy, and sequestered and non-sequestered disc herniations can be operated on with this technique, and these pathologies can be addressed. Patients with compressive foraminal or extraforaminal pathologies, extensive spinal canal stenoses, a significant bony shift in the interlaminar window, and instability in the spinal canal are excluded. The goal of this study is to describe the full-endoscopic interlaminar approach for lumbar lateral recess stenosis.

<table><tbody><tr><td>Burr Oval &amp;Oslash; 5.5 mm</td><td>RiwoSpine</td><td>899751505</td><td>PACK = 1 PC, WL 290 mm, with lateral protection</td></tr><tr><td>C-arm</td><td>ZIEHM SOLO</td><td></td><td>C-arm with integrated monitor</td></tr><tr><td>Dilator ID 1.1 mm OD 9.4 mm</td><td>RiwoSpine</td><td>892209510</td><td>For single-stage dilatation, TL 235 mm, reusable</td></tr><tr><td>Endoscope</td><td>RiwoSpine</td><td>892103253</td><td>20 degrees viewing angle and 177 mm length with a 9.3 mm diameter oval shaft with a 5.6 mm diameter working channel</td></tr><tr><td>Kerrison Punch 5.5 mm X 4.5 mm WL 380 mm</td><td>RiwoSpine</td><td>892409445</td><td>60&lt;sub&gt;&amp;deg;&lt;/sub&gt;, TL 460 mm, hinged pushrod, reusable</td></tr><tr><td>Punch &amp;Oslash; 3 mm WL 290 mm</td><td>RiwoSpine</td><td>89240.3023</td><td>TL 388 mm, with irrigation connection, reusable</td></tr><tr><td>Punch &amp;Oslash; 5.4 mm WL 340 mm</td><td>RiwoSpine</td><td>892409020</td><td>TL 490 mm, with irrigation connection, reusable</td></tr><tr><td>Radioablator RF BNDL</td><td>RiwoSpine</td><td>23300011</td><td></td></tr><tr><td>RF Instrument BIPO &amp;Oslash; 2.5 mm WL 280 mm</td><td>RiwoSpine</td><td>4993691</td><td>for endoscopic spine surgery, flexible insert, integrated connection cable WL 3 m with device plug to Radioblator RF 4 MHz, sterile, for single use&amp;nbsp;</td></tr><tr><td>Rongeur &amp;Oslash; 3 mm WL 290 mm</td><td>RiwoSpine</td><td>89240.3003</td><td>TL 388 mm, with irrigation connection, reusable</td></tr><tr><td>Working sleeve ID 9.5 mm OD 10.5 mm</td><td>RiwoSpine</td><td>8922095000</td><td>TL 120, distal end beveled, graduated, reusable</td></tr></tbody></table>

full-endoscopic interlaminar approach for decompression of lateral recess stenosis

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

The preoperative and postoperative sagittal and axial magnetic resonance images (MRIs) show right-sided lateral recess stenosis. (Figure 1). Due to the continuous irrigation and suction system in full-endoscopic surgery, the blood loss could not be measured. However, postoperative hemoglobin levels indicate that no significant blood loss is experienced. Early postoperative mobilization is encouraged for the patients, who are usually discharged the day after. A lumbar corset is not required s...

Technical advances and increased experience in full-endoscopic spinal surgeries enable these procedures to be performed with minimal incision, muscle retraction, and bone removal.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming ...

To begin, remove the soft tissues, mainly the paraspinal muscles, using the rongeur. Remove the superficial layer of the ligamentum flavum with a 5.4-millimeter punch for a total exposure of the descending facet. To expose the ascending facet, use the 5.5-millimeters oval bur with lateral protection and remove the bone from the medial side of the descending facet from its inferior tip.Use the oval bur with lateral protection again for thinning the ascending facet so that the total removal can be achieved by the Kerrison punch. Use the Kerrison punch for further bone removal toward the lateral, then resect the ligamentum flavum using the punch from the midline toward the lateral. Ensure that the ligamentum flavum is removed from medial to lateral and cranial to caudal to visualize the lateral recess completely.Then, using the rongeur, cautiously remove the epidural fat tissue until adequate exposure to the neural structures is obtained. Mobilize the nerve root medially using the dissector to relieve it from any adhesions. Address any discopathy contributing to the lateral recess stenosis.Medialize the nerve root using the dissector or turn the long side of the working sleeve. Achieve decompression by resecting half of the pedicle and the ligamentum flavum at the lateral recess. The preoperative sagittal and axial magnetic resonance images show right-sided lateral recess stenosis.Postoperative images confirm the resolution of this finding.

full-endoscopic-interlaminar-approach-for-decompression-lateral

Research

JoVE Journal

Medicine

Presented here is a novel technique of C-arm free transtubular posterolateral decompression for lumbar foraminal stenosis and lateral disc herniation under O-arm navigation.

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation

Here, we present a protocol to describe the full endoscopic interlaminar approach (FEILA) technique, including every cutoff step required to reach technical proficiency. FEILA is a surgery with a relatively steep learning adaptation. Despite this, any surgeon capable of microdiscectomy can perform FEILA with enough practice and suitable patient selection.

Full Endoscopic Interlaminar Approach for Paracentral L5-S1 Disc Herniation

Here, we present the third channel-assisted UBE technique, which allows for the vertical removal of herniated disc fragments. This technique can effectively address the limitations of traditional UBE techniques. This article will systematically elaborate on this procedure.

The Third Channel-Assisted Unilateral Biportal Endoscopic Technique for Lumbar Spinal Stenosis Combined with Contralateral Disc Herniation

The present protocol describes the steps and key points of lumbar endoscopic unilateral laminotomy for bilateral decompression for the treatment of degenerative lumbar spinal stenosis.

Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis

This protocol provides a step-by-step guide for performing transforaminal full-endoscopic foraminotomy under local anesthesia. This motion-preserving technique is presented as a minimally invasive surgical alternative to fusion extension for treating L5/S1 foraminal stenosis in patients with adjacent segment disease.

Transforaminal Full-Endoscopic Lumbar Foraminotomy Under Local Anesthesia for L5/S1 Adjacent Segment Foraminal Stenosis

Meatoplasty, surgical management of meatal stenosis.

Surgical Management of Meatal Stenosis with Meatoplasty

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

An aortocaval fistula was created by puncturing the murine infra-renal aorta through both walls into the inferior vena cava and was followed by creation of a stenosis in its outflow via partial ligation of the inferior vena cava. This reproducible model can be used to study central venous stenosis.

Murine Model of Central Venous Stenosis using Aortocaval Fistula with an Outflow Stenosis

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

We describe a novel, cost-effective, and efficient technique for percutaneous delivery of three-dimensionally printed coronary implants to create closed-chest swine models of ischemic heart disease. The implants were fixed in place using a mother-and-child extension catheter with high success rate.

Novel Percutaneous Approach for Deployment of 3D Printed Coronary Stenosis Implants in Swine Models of Ischemic Heart Disease

Learn full-endoscopic spinal decompression techniques for lateral recess stenosis using specialized instruments like rongeurs, punches, and oval burs. This minimally invasive approach improves surgical outcomes.

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis

Explore More Videos