Comparative Cohort Study for Expansion of Lateral Recess and Facet Joint Injury after Biportal Endoscopic Ipsilateral Decompression and Contralateral Decompression.

STUDY DESIGN: This was a retrospective longitudinal study of patients operated on consecutively in a single center from May to October 2019. PURPOSE: The aim in biportal interlaminar endoscopic decompression surgery for lumbar stenosis is to compare the clinical and radiological outcome of lateral recess decompression and facet preservation, employing ipsilateral (IL) versus contralateral (CL) approaches. OVERVIEW OF LITERATURE: There is scant literature comparing the radiological outcome of lateral recess decompression and facet preservation via IL versus CL approaches in patients undergoing biportal interlaminar endoscopic decompression surgery. METHODS: In this retrospective study, we reviewed 37 IL and 34 CL approaches. Postoperative magnetic resonance imaging of the segment involved was carried out on the same day as the operation for comparison with preoperative imaging. Radiological assessments of recess angle, recess height, facet length, and recess dural sac diameters were compared. In addition, pre- and postoperative Visual Analog Scale (VAS) pain scores for the lower limb were analyzed. RESULTS: For IL versus CL approaches, we observed statistical differences in the postoperative recess angle (36.0° vs. 43.7°), recess height (4.27 vs. 5.06 mm), and the dural sac expansion ratio for recess diameter (1.54 vs. 2.17). There was better preservation of facet length in the CL approach than in the IL approach (91.9% vs. 83.7%). There was no difference in VAS improvement between the groups (69.3% vs. 63.6%). CONCLUSIONS: Unilateral biportal decompression via the CL interlaminar approach may offer better lateral recess clearance and facet preservation than can be achieved via the IL approach. Larger-scale studies are needed for better delineation and for correlation of radiological features with clinical manifestations.

Unilateral Bi-portal Endoscopic Decompression via the Contralateral Approach in Asymmetric Spinal Stenosis: A Technical Note.

We discuss the technical details and operative advantages of approaching pathologies from the contralateral side in cases of asymmetric spinal stenosis. The contralateral approach offers better manipulative freedom and a more accessible target approach along the plane of the pathology, allowing safer decompression and facet preservation; further, this approach is ergonomic for surgeons. We recommend the adoption of this approach in decompressing asymmetric spinal stenosis.

The Feasibility and Perioperative Results of Bi-Portal Endoscopic Resection of a Facet Cyst Along With Minimizing Facet Joint Resection in the Degenerative Lumbar Spine.

BACKGROUND: Presentation of degenerative facet cysts (FC) as radicular pain in patients is well established. The traditional treatment of FCs has been decompressive laminectomy with a medial facetectomy and cyst excision. A major disadvantage of open procedures with medial facetectomy is predisposition to further instability. OBJECTIVE: To describe a contralateral bi-portal endoscopic excision of FC along with minimizing facet joint resection. METHODS: Thirteen patients between March 2016 and December 2017 were evaluated retrospectively for clinical, radiological, and morphometric outcomes. Patients with complaints of unilateral radiculopathy with associated neurogenic claudication from degenerative lumbar FC were included. Clinical evaluation was by NRS leg pain and ODI scores, radiological evaluation was by MRI. For morphometric analysis, cross-sectional area of facet joint (CSA-FJ) was measured on MRI in square millimeters. RESULTS: Thirteen FCs were decompressed (no adverse events) NRS leg pain and ODI improved from 6.85 ± 0.69 and 65.08 ± 7.95 preoperatively to 1 ± 0.91 and 13.46 ± 5.19 at 1-yr follow-up, respectively. CSA-FJ remained relatively well preserved from 212.83 ± 58.05 to 189.77 ± 62.93 post decompression (statistically insignificant, P = .3412). CONCLUSION: Bi-portal endoscopic decompression of FC can be performed with good clinical and radiological outcomes. This surgical technique may be recommended for further evaluation as an addition in the armamentarium of a spine surgeon for treatment of degenerative lumbar FC.

Full Endoscopic Technique for High-Grade Up-Migrated Lumbar Disk Herniation via a Translaminar Keyhole Approach: Preliminary Series and Technical Note.

BACKGROUND AND STUDY AIMS: Technically and anatomically, accessing a high-grade migrated lumbar disk herniation (LDH) using traditional full endoscopic lumbar diskectomy (FELD) approaches (either transforaminal or interlaminar) is challenging. The objective of this study was to present an effective and safe surgical approach for high-grade up-migrated LDH by translaminar FELD. PATIENTS AND METHODS: Thirteen patients with soft high-grade up-migrated LDH treated with a translaminar FELD between May 2015 and July 2018 were reviewed in this study. Five of these patients had very high-grade up-migration. Clinical outcomes were assessed including preoperative and postoperative visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria. RESULTS: Overall, 7 of the 13 patients had disk-fragment migration at L4-L5: three at L5-S1, two at L3-L4, and the remaining one at L2-L3. In all cases, the highly up-migrated LDH was removed successfully through the translaminar approach, as confirmed by postoperative magnetic resonance imaging. The improvements of VAS for back and leg pain were 4.5 ± 0.9 to 1.3 ± 1.3 and 7.1 ± 1.0 to 1.6 ± 0.7, respectively (both p < 0.05). The ODI decreased from preoperative 41.9 ± 6.0 to postoperative 13.0 ± 4.1 (p < 0.05). According to the MacNab criteria, the satisfaction rate was 92.3% (excellent or good outcomes). None of the patients experienced any perioperative complications or recurrence during the follow-up period. CONCLUSION: Although full endoscopic technique via the translaminar keyhole route may not be used as a routine surgical approach, it could serve as a feasible alternative method for patients with highly up-migrated disk herniation.

Biportal Endoscopic Decompression of Exiting and Traversing Nerve Roots Through a Single Interlaminar Window Using a Contralateral Approach: Technical Feasibilities and Morphometric Changes of the Lumbar Canal and Foramen.

BACKGROUND: Endoscopic surgery for lumbar stenosis is gaining acceptance because of the minimal muscle damage, short recovery times, reduced blood loss, and good clinical results. We report a novel technique of decompressing contralateral traversing and exiting nerve roots through a single interlaminar window, avoiding separate incision for foraminal decompression with minimal damage to facet joints and comparing morphometric changes after decompression. METHODS: Between March and December 2017, 30 patients were evaluated retrospectively for clinical, radiologic, and morphometric outcomes. Patients with unilateral radiculopathy and magnetic resonance imaging (MRI) showing spinal stenosis at 2 levels (lateral recess and cranial level foraminal compression) were included. Clinical evaluation used a numerical rating scale (NRS) for leg pain and Oswestry Disability Index (ODI) scores, and radiologic evaluation used MRI. For morphometric analysis, the cross-sectional area of the intervertebral foramen (CSA-IVF), spinal canal (CSAC), and facet joint (CSA-FJ) was measured on MRI. RESULTS: Thirty levels were decompressed (no adverse events). NRS leg pain and ODI scores improved from 7.5 ± 0.86 and 67.9 ± 9.7 preoperatively to 1.53 ± 0.86 and 15.7 ± 6.6 at last follow-up, respectively. CSAC improved from 99.34 ± 34.01 to 186.83 ± 41.41, indicating good canal decompression. CSA-IVF improved from 56.40 ± 19.28 to 97.60 ± 28.46, indicating good foraminal decompression. CSA-FJ improved from 231.37 ± 62.53 to 194.96 ± 50.56, indicating good foraminal decompression with less damage to facet joint. Morphometric changes were statistically significant (P < 0.05). CONCLUSIONS: Biportal endoscopic decompression of the lateral recess and cranial foramen through a single interlaminar window can be performed using a contralateral approach. In view of the good clinical and radiologic outcomes of patients, with notable improvements in morphometric measurements at stenosed segments, this surgical technique is worthy of further evaluation and application.

Posterior Percutaneous Endoscopic Cervical Foraminotomy and Diskectomy With Unilateral Biportal Endoscopy.

This report describes a new, minimally invasive procedure, posterior percutaneous endoscopic cervical diskectomy, performed with a unilateral biportal endoscopic approach. The procedure is used to treat cervical foraminal soft disk protrusion. This report also describes the short-term results with this procedure. In 2015, 14 patients underwent this new, minimally invasive procedure. The technique was applied with a standard arthroscopy device and conventional spine instruments. The Neck Disability Index and visual analog scale scores for the neck and upper arm were evaluated, and 13 consecutive patients were included in the analysis. Mean follow-up was 14.8 months (range, 12-18 months). The Neck Disability Index decreased from 27.0±2.5 to 6.8±1.4 at the last follow-up (P<.05). Visual analog scale scores for the neck and upper arm also decreased significantly (neck, 6.2±0.8 to 2.4±0.9; upper arm, 7.0±1.1 to 2.2±0.6). Posterior percutaneous endoscopic cervical diskectomy with a uniportal endoscope provides a clear operative field because of continuous endoscopic saline irrigation and requires only a short hospitalization and no postoperative rehabilitation. Posterior percutaneous endoscopic cervical diskectomy with a unilateral biportal endoscopic approach also can be performed efficiently because of the wide field of visualization and familiar surgical field. Thus, posterior percutaneous endoscopic cervical diskectomy with the unilateral biportal endoscopic approach may be an alternative procedure for cervical foraminal soft disk protrusion. [Orthopedics. 2017; 40(5):e779-e783.].