Visitec Lacrimal Trephine [Sisler], .80 mm x 38 mm (21G ...

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To (i) introduce the technical notes of a novel full‐endoscopic foraminotomy with a large endoscopic trephine for the treatment of severe degenerative lumbar foraminal stenosis at L 5 S 1 level; (ii) assess the primary clinical outcomes of this technique; (iii) compare the effectiveness of this full‐endoscopic foraminotomy technique and other previous techniques for lumbar foraminal stenosis. From January 2019 to August 2019, a retrospective study of L 5 S 1 severe degenerative lumbar foraminal stenosis was performed in our center. All patients who were diagnosed with severe foraminal stenosis at L 5 S 1 level and failed conservative treatment for at least 6 weeks were identified. Patients with segmental instability or other coexisting contraindications were excluded. A total of 21 patients were enrolled in the study. All patients were treated by full‐endoscopic foraminotomy using large endoscopic trephine. The visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated preoperatively and at 1, 3, 6 months, and 1 year after the surgery, and the modified MacNab criteria were used to evaluate clinical outcomes at the last follow‐up. There were 10 males and 11 females with a mean age of 66.38 ± 9.51 years. Five patients had a history of lumbar surgery. The mean operative time was 63.57 ± 25.74 min. The mean follow‐up time was 13.29 ± 1.38 months. The mean postoperative hospital stay time was 1.29 ± 0.56 days. The mean preoperative VAS score significantly decreased from 7.38 ± 1.02 to 2.76 ± 1.09 (t = 19.759, P < 0.01), 2.25 ± 1.02 (t = 21.508, P < 0.01), 1.60 ± 1.05 (t = 31.812, P < 0.01), and 1.45 ± 1.10 (t = 25.156, P < 0.01) at 1 month, 3 months, 6 months, and 1 year after the operation. The mean preoperative ODI score significantly decreased from 64.66% ± 4.91% to 30.69% ± 4.59% (t = 33.724, P < 0.01), 29.44% ± 4.50% (t = 32.117, P < 0.01), 24.22% ± 4.14% (t = 33.951, P < 0.01), and 22.44% ± 4.94% (t = 30.241, P < 0.01) at 1 month, 3 months, 6 months, and 1 year after the operation. At the last follow‐up, 19 patients (90.48%) got excellent or good outcomes. One patient suffered postoperative dysesthesia, and the symptoms were controlled by conversion treatment. One patient took revision surgery due to the incomplete decompression. There were no other major complications. Percutaneous endoscopic decompression is minimally invasive spine surgery. However, the application of endoscopic decompression for L 5 S 1 foraminal stenosis is relatively difficult due to the high iliac crest and narrow foramen. Full‐endoscopic foraminotomy with the large endoscopic trephine is an effective and safe technique for the treatment of degenerative lumbar foraminal stenosis.

We described an advanced percutaneous endoscopic lumbar foraminotomy by using a specially designed endoscopic trephine. The hard bony decompression was performed directly under endoscopic observation. It combined the efficiency of trephine and the safety of the instruments guided by the endoscope. A safe and effective full‐range decompression of the exiting nerve root was achieved by this technique.

Introduction

Degenerative lumbar spinal stenosis results from gradual degenerative changes in the lumbar spine and can significantly affect mobility, function, and quality of daily life. Degenerative lumbar spinal stenosis is a common disease among the geriatric population and the most frequent indication for spinal surgery. Lumbar foraminal stenosis is a special type of lumbar spinal stenosis.

The lumbar intervertebral foramina is a round, oval, or inverted teardrop zone lateral to the spinal canal. The anatomical boundaries of the lumbar foramina are as below: the upper boundary is the superior vertebral pedicle; the lower boundary is the inferior vertebral pedicle; the anterior boundary is the intervertebral disc, the posteroinferior part of the upper vertebral body, and the posterosuperior part of the lower vertebral body; the posterior boundary is the facet joint and the ligamentum flavum (LF). The normal area of lumbar foramina ranges from 40 to 160 mm2, and the height of lumbar foramina ranges from 20 to 23 mm. The exiting nerve root and dorsal root ganglia through the lumbar foramina are surrounded by radicular vessels and fat. The nerve runs in the anterosuperior part of the foramina, which is between the superior transforaminal ligaments and the inferior transforaminal ligament 1 . The ratio of the exiting nerve root and dorsal root ganglia to the foraminal area could reach 30% 2 .

Degenerative lumbar foraminal stenosis is defined as neural foraminal narrowing caused by the diminishment of the foraminal height, hypertrophy of the facet joint and ligamentum flavum (LF), subluxation of the superior articular process (SAP), osteophytes, and lateral disc herniations 3 . Far lateral disc herniation, foraminal height decrease, and posterolateral osteophytes could compress the exiting nerve root to the superior pedicle, which results in the vertical stenosis of the foramen. Hypertrophic LF and facet joint, subluxation of the SAP, and bony spurs could compress the exiting nerve root which leads to the transverse stenosis of the foramen. A combination of vertical stenosis and transverse stenosis could cause the circumferential stenosis of the foramen. The nerve will be compressed severely in the circumferential foraminal stenosis that most of this area may need surgical treatment. The buckling of the LF caused by foraminal height decrease also contributes to the circumferential foraminal stenosis. A previous study pointed out that foraminal height less than 15 mm and posterior disc height less than 4 mm will result in significant nerve compression.

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Lumbar foraminal stenosis tends to occur in the lower lumbar levels. A previous study reported that 75% of lumbar foraminal stenosis occurred in the L5S1 level 4 . The reason may be related to the following factors. First, the diameter of the L5 dorsal root ganglia is the biggest (8.3 mm) and could occupy nearly 51.2% of the available foraminal area. Second, the LF coverage ratio of the foraminal area was largest in the L5S1 level 5 . This also indicates the LF is more likely to buckle and compress the nerve when L5S1 foraminal height decreases. Finally, the lumbosacral junction level, the mobility, and loading of the L5S1 level are larger than other levels. This also makes L5S1 level tend to occur degeneration, which result in disc herniation, disc height loss, facet joint, and LF hypertrophy.

Lumbar exiting nerve root and dorsal root ganglia could be compressed by lumbar foraminal stenosis, and result in low back pain and radicular symptoms. The incidence of lumbar foraminal stenosis was reported as 8%–11% 4 , 6 . The previous study pointed out that nearly 60% of failed back surgery syndromes were caused by unrecognized and incomplete decompression of lumbar foraminal stenosis 7 .

Conventional open paraspinal foraminotomy or foraminoplasty has been considered as the golden standard treatment for lumbar foraminal stenosis 8 , 9 . However, open surgery would have more surgical trauma and take a longer time for postoperative recovery 10 . Moreover, some patients suffered postoperative radicular pain or dysesthesia, which was attributed to the excessive manipulation of the dorsal root ganglion or incomplete decompression 9 , 11 .

To solve these problems, minimally invasive spine surgery including percutaneous endoscopic foraminal discectomy or foraminoplasty was developed 12 , 13 , 14 , 15 . These techniques had many advantages including less bleeding, minor surgical trauma, a shorter hospital stay, and a rapid postoperative functional recovery 16 , 17 , 18 . However, most of these minimally invasive techniques used were limited to the soft disc and to mild or moderate foraminal stenosis due to a lack of effective decompression tools. For bony and severe foraminal stenosis especially at L5S1 level, where the obstruction of the high iliac crest and L5 transverse process exist 19 , a safe, complete, and effective decompression remains a great challenge.

In the present study, we performed endoscopic foraminotomy by using the large endoscopic trephine for degenerative lumbar foraminal stenosis at the L5S1 level, which placed the procedure of bony decompression directly under endoscopic observation. The objective of the present study was to: (i) describe the technical notes of this full‐endoscopic foraminotomy with a novel large endoscopic trephine for the treatment of severe degenerative lumbar foraminal stenosis at L5S1 level; (ii) assess the primary clinical outcomes of this technique; (iii) compare the effectiveness of this full‐endoscopic foraminotomy technique and other previous techniques for lumbar foraminal stenosis.

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