Name: Author Spotlight: Scope of LE-ULBD as a Safe, Effective, and Minimally Invasive Approach to Treat Lumbar Spinal Stenosis
Uploaded: 2024-02-09T12:50:00
Description: Read this Scientific Article Protocol about Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis at JoVE.com

This study was conducted in strict accordance with the protocols established by the Institutional Review Boards of Zhongshan Hospital and Minhang Hospital, both affiliated with Fudan University (approval numbers: 2021-042 and 2021-037-01X, respectively). All participating patients provided informed written consent. Exclusion criteria were rigorously applied: patients with foraminal stenosis, multi-level stenosis, significant instability, a medical history of previous lumbar spine surgical interventions, or those presenti...

Treating Lumbar Spinal Stenosis with a Minimally Invasive Spine Surgery

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With the progressive evolution of percutaneous endoscopic spine surgery and clinicians&#39; profound comprehension of endoscopic procedures, the therapeutic indications for endoscopic lumbar interventions have expanded to encompass all manifestations of LSS, branching out from merely addressing lumbar disc herniation. The spectrum of endoscopic management for LSS includes stenosis decompression, contralateral decompression, and fusion facilitated by endoscopic visualization. An increasing volume of research underscores t...

Degenerative lumbar spinal stenosis (DLSS) can result from alterations in bony, discal, capsular, or ligamentary anatomical structures. Clinically, LSS presents with a range of symptoms, including radiating sciatic pain in the legs, neurogenic claudication during ambulation, and sensory disturbances, all of which significantly affect patients&#39; quality of life1,2,3. An initial conservative management period of two months is the recommended therapeutic approach for LSS. If conservative measures prove ineffective, transitioning to surgical decompression therapy becomes the subsequent recommendation.
Historically, open laminectomy has been the traditional surgical approach for addressing spinal stenosis. Peer-reviewed studies have confirmed its safety and cost-effectiveness, with outcomes showing notable superiority compared to non-surgical interventions4,5,6,7,8. However, the complexities involved in achieving comprehensive bony decompression of neural components can introduce the risk of segmental spinal instability. This may lead to symptom recurrence or a subsequent need for arthrodesis9,10. Distinctively, Ghogawala et al.11 documented that approximately 34% of patients, after undergoing traditional laminectomy for lumbar spinal stenosis with concomitant stable spinal spondylolisthesis, required revision surgery within four years post-operatively.
Over the past five decades, a discernible shift toward minimally invasive spinal surgical procedures has become evident. The overarching objective has been to reduce approach-related tissue disruption and subsequently mitigate post-operative discomfort and disability. This transition aligns seamlessly with the advent and progression of percutaneous endoscopic spine surgery.
Synchronized with advancements in endoscopic technology and a deepened understanding of endoscopic anatomical intricacies, contemporary endoscopic spine surgeons are now equipped to address a spectrum of LSS presentations safely and effectively. Specifically, lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has gained traction as a favored modality for LSS management12,13,14,15,16,17(Figure 1). Paramount benefits of LE-ULBD include minimal incision requirements, avoidance of soft tissue disruption and muscular denervation, along with improved visualization.
Between May 2017 and May 2021, our institution employed the LE-ULBD technique to manage 132 patients with LSS. Relevant technical details and outcomes over a two-year follow-up period are elucidated herein. Based on these findings, LE-ULBD emerges as a minimally invasive, effective, and secure modality, positioning it as a viable alternative therapeutic strategy for patients diagnosed with lumbar central canal stenosis and/or lateral recess stenosis.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Kerrison Rongeur&#160;</td>
			<td>Joimax GmbH, Karlsruhe, Germany</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>The endoscopic high-speed&#160;diamond burr</td>
			<td>NSK-Nakanishi International, Co., Ltd., Osaka, Japan</td>
			<td>Primado P200-RA330</td>
			<td></td>
		</tr>
		<tr>
			<td>The endoscopic surgical system Delta</td>
			<td>Joimax GmbH, Karlsruhe, Germany</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>The radiofrequency probe</td>
			<td>Elliquence LLC, Baldwin, New York</td>
			<td>Trigger-FlexR Bipolar System</td>
			<td></td>
		</tr>
		<tr>
			<td>Trephine</td>
			<td>Joimax GmbH, Karlsruhe, Germany</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

percutaneous endoscopic unilateral-approach bilateral decompression for lumbar spinal stenosis

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ligaments. LSS encompasses central canal stenosis (CCS), lateral recess stenosis (LRS), and intervertebral foramen stenosis (IFS). The utilization of lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has gained popularity in the treatment of CCS and LRS. This popularity is attributed to the rapid development of endoscopic instruments and the progress of endoscopic philosophy.
In this technical report, a detailed introduction to the steps and key points of LE-ULBD is provided. Simultaneously, a retrospective review of 132 consecutive patients who underwent LE-ULBD for central canal and/or lateral recess stenosis was conducted. The outcomes after more than two years of follow-up were assessed using the visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, and the modified MacNab criteria to evaluate surgical efficacy. All 132 patients underwent LE-ULBD successfully. Among them, 119 patients were rated as "excellent," while 13 patients were rated as "good" based on the modified MacNab criteria during the last follow-up. Incidental dural tears occurred in four cases, but there were no post-operative epidural hematomas or infections. The experience demonstrates that LE-ULBD is a less invasive, effective, and safe approach. It can be considered as an alternative option for treating patients with lumbar central canal stenosis and/or lateral recess stenosis.

Author Spotlight: Scope of LE-ULBD as a Safe, Effective, and Minimally Invasive Approach to Treat Lumbar Spinal Stenosis

Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis

The present protocol describes the steps and the key points of lumbar endoscopic unilateral laminotomy for bilateral decompression, LE-ULBD. This technique is used to treat degenerative lumbar spinal stenosis. The paramount advantage is that LE-ULBD provides an unparalleled clear visualization of the surgical field while reducing surgical-related trauma.Endoscopic spine surgery was initially used for lumbar disc herniation. However, it had evolved dramatically in recent years with the rapid development of endoscopic equipment and technological innovations. We have always been committed to broaden the scope of indications of spinal endoscopic technique.For example, we are developing percutaneous full-endoscopic C2 ganglionectomy to treat intractable occipital neuralgia.

Outcome evaluation
Surgical results were assessed using the Visual Analog Scale (VAS) scores for leg and back pain, Japanese Orthopaedic Association (JOA) Scores, Oswestry Disability Index (ODI) scores, and the modified MacNab standard12,15,17. These indicators were measured pre-operatively and at two days, six months, ...

Read this Scientific Article Protocol about Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis at JoVE.com

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.

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ...

percutaneous-endoscopic-unilateral-approach-bilateral-decompression

Research

JoVE Journal

Medicine

Performing Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression

To begin, position the patient in a prone position on a radiolucent operating table and appropriately flex the patient. Identify the specific lumbar segment responsible for the clinical symptoms as the target for the surgical procedure. Determine the skin incision site and the point for docking the working channel on the anteroposterior view of fluoroscopy.Select the lateral edge of the left lumbar four to five interlaminar window as the docking target and identify its vertical projection on the body surface as the entry point for the skin. Create a 10-millimeter stab incision through the skin, reaching deep to the fascia layer. Guided by fluoroscopy, introduce a pencil-like rod, with a two-millimeter diameter, till it touches the left L4 to 5 articular bone.Using a soft tissue extender, gradually enlarge the opening through the vertebral muscle and fascia. Subsequently, insert a 10-millimeter triangular work sleeve with an oblique opening. Next, take the appropriate endoscopic surgical system and introduce the same through the opening to perform the subsequent steps under continuous irrigation and endoscopic visualization.Under high-definition endoscopic visualization, dissect the soft tissue from the bone and achieve hemostasis, using the Radio Frequency Pro. Start the ipsilateral bony decompression, commencing at the L4 lamina, utilizing a 3.5 millimeter endoscopic diamond burr, five millimeter trephine, and Kerrison Rongeur, remove the lower section of the L4 lamina and the medial part of the L4 to 5 articular processes. With the trephine, effectively remove the L4 inferior articular process, enclosed by the joint capsule and ligament, remove the upper edge of the L5 lamina.Using a Rongeur, separate and remove the superficial layer of the ligamentum flavum from the inner layer. Cut the medial edge of the L5 superior articular process to release the lateral border of the ligamentum flavum. Next, proceed with contralateral bony decompression, commencing at the base of the L4 spinous process.Polish the contralateral lower portion of the L4 lamina from the inner surface, to expose the cephalad margin of the ligamentum flavum. Detach the contralateral lateral margin of the ligamentum flavum from the contralateral L5 superior articular process, using a diamond burr or Kerrison Rongeur or both, remove the medial section of the L5 superior articular process. Upon completing bony decompression and releasing ligamentum flavum attachments, remove the ligamentum flavum either in an En bloc manner or in a piecemeal manner.Examine both lateral recesses to ensure thorough decompression of bilateral traversing nerves. Using endoscopic radiofrequency bipolar, achieve meticulous hemostasis. Close the skin incision with one or two stitches, each approximately one centimeter in length.Patients exhibited satisfactory results at the end of the 24-month follow-up period after the lumbar endoscopic unilateral laminotomy for bilateral decompression. There was a significant improvement in the visual analog scores, Japanese Orthopedic Association scores, and Oswestry Disability Index, over time.