14 Tubular Endoscopic Lumbar Laminoforaminotomy and Diskectomy [2]

Compression of neural structures in the lumbar spine is frequently caused by disk herniation. Lumbar radiculopathy is one of the most common symptoms that spine surgeons have to deal with. If conservative treatment is unsuccessful, surgery should be considered. Lumbar diskectomy and radicular decompression have been the most commonly performed surgical procedures for pathologies in this region for many decades.1,2,3 While the traditional open approach resulted in damage to the paraspinal muscles, the technique was further refined by using an operating microscope, which offered better illumination and which allowed “mini-open” approaches in the 1970s. However, significant iatrogenic trauma was still associated with the technique.^2,3

In the early 1990s, percutaneous dilation systems were introduced to lumbar spine surgery. The idea was to dilate the muscles instead of dissecting them from the osseous structures. In 1996, Foley and Smith introduced a system that enabled the surgeon to perform lumbar disk surgery in a standard open bimanual microsurgical technique via endoscopic visualization. Approaching the lumbar spine via dilation of the paraspinal muscles offers the advantage of less muscular damage, decreased postoperative pain, faster recovery, and shorter hospital stay.^4,5,6,7,8,9 Even recurrent disk prolapse can be successfully approached.¹⁰ While the mid-term results are identical to the standard microdiskectomy, short-term benefits of the application of a tubular system are obvious. This chapter describes the technique for laminoforaminotomy and diskectomy using a tubular endoscopic system (EasyGO!, Karl Storz GmbH & Co. KG, Tuttlingen, Germany).

• MRI showed a central spinal stenosis with medial disk herniation and partial caudal migration in segment L4–L5 (Fig. 14.1).

14.5 Preoperative Plan

• Careful analysis of the ideal surgical approach is done based on preoperative imaging data (MRT, CT, myelogram, postmyelogram CT).

• If spinal instability cannot be ruled out, lateral, flexion, and extension X-rays are recommended.

14.6 Patient Positioning and Anesthesia (Video 14.1)

• The procedure is performed under general anesthesia. Perioperative antibiotics are administered.

• The patient is placed centered on the operating table in the prone position. The neck is in neutral position, and the abdomen is decompressed on a Wilson frame. Pressure points are padded, and a C-arm for lateral fluoroscopy is installed to identify the affected segment (Fig. 14.2).

• Skin incision is ~ 2 cm paramedian of the spinous process on the affected side. A longitudinal incision ~ 1.0 to 2.5 cm long, depending on the selected trocar, is made (Fig. 14.3).

• The muscle fascia is opened. While some surgeons recommend application of a guidewire, the authors prefer to put the smallest dilator in direct contact with the bony surface of the upper vertebral lamina under lateral fluoroscopic control. Soft tissue and muscles are pushed away and dilated by sliding the various dilators one over the other. After tissue dilation, the working trocar is placed on the lamina-facet complex and fixed in position by connection to the endoscope holding arm (Fig. 14.4).

• The endoscope, which is connected to the three-chip high-definition (HD) camera head as well as the light cable, is introduced.

• The full-HD endoscopic unit is generally positioned contralateral to the surgeon so that the surgeon can assume a comfortable position while operating using the bimanual technique (Fig. 14.5).

14.7 Endoscopic Surgical Technique (Video 14.2)

• After insertion of the 30° endoscope (Fig. 14.6), bipolar cautery and grasper (left and middle) are used for removal of remnant muscle tissue in order to display the osseous part of the spinous process (right, white strips), the lamina (white stars), and the interlaminar window (small arrow).

• In cases of hyperostosis and/or ossification of the ligament, a diamond drill should be used for partial laminectomy to expose the ligamentum flavum (Fig. 14.7). The authors recommend a diamond drill to reduce the risk of dural tear and the risk of injury to the nerve fascicles (upper row). When the interlaminar fenestration is large enough, a dissector or nerve hook (lower row, middle picture) is used to detach the ligamentum flavum from the undersurface of the lamina starting from medial to lateral.

• Once the ligamentum flavum is detached from the lamina, a Kerrison punch is used to remove the ligament and to continue with the laminotomy from medial to lateral and cranial to caudal.

• Subsequently, the interlaminar fenestration is enlarged and the decompression is directed laterally and caudally to the neuroforamen. The working channel may be need to be repositioned to achieve optimum view at the surgical field.

• If necessary, resection of the most medial part of the facet should be performed.

• Lateral fluoroscopy may be used intraoperatively to control the extent of the laminotomy or foraminotomy.

• After foraminotomy and decompression of the nerve root, a nerve hook should be passed into the neuroforamen to verify adequate decompression (Fig. 14.8).

• After exposure and decompression of the nerve root, a nerve hook is used to mobilize the nerve root medially and to expose the posterior longitudinal ligament (PLL) to visualize the subligamentous disk herniation.

• Scissors are used to open the PLL.

• Subsequently, the disk herniation is removed with a grasper, and diskectomy is performed (Fig. 14.9).

• After laminoforaminotomy and diskectomy, a nerve hook is used to verify adequate decompression.

• In cases of diffuse bleeding, a collagen sponge coated with the human coagulation factors fibrinogen and thrombin is helpful to control bleeding (Fig. 14.10).

• After laminoforaminotomy and diskectomy, it is recommended that the working trocar be removed under endoscopic control to detect and immediately treat bleeding sources in the paraspinal muscle. The thoracolumbar fascia can be closed using 2.0 interrupted sutures in thin patients. In obese patients, it is advisable to coapt subcutaneous tissue, followed by use of subcuticular suture. Skin adhesive allows the patient to shower on the first postoperative day.

Related posts:

Percutaneous Endoscopic Lumbar Diskectomy: Extraforaminal Approach Endoscopic Radiofrequency Denervation for Treatment of Chronic Low Back Pain Tubular Lumbar Decompressive Laminectomy and Foraminotomy Endoscopic Removal of Intradural Extramedullary Space-Occupying Lesions Foramen Magnum Decompression of Chiari Malformation Using Minimally Invasive Tubular Retractors Percutaneous Endoscopic Interlaminar Lumbar Diskectomy: Structural Preservation Technique for L5-S1 Herniated Nucleus Pulposus

Stay updated, free articles. Join our Telegram channel

Join