The Role of Percutaneous Transforaminal Endoscopic Surgery in Lateral Recess Stenosis in Elderly Patients

STUDY DESIGN: Prospective clinical study. PURPOSE: To investigate the effect of percutaneous transforaminal endoscopic surgery (PTES) for lateral recess stenosis (LRS)(LRS) in elderly patients and to assess patients’ health-related quality of life (HRQoL). OVERVIEW OF LITERATURE: PTES is an increasingly used surgical approach, primarily employed for lumbar disc herniation treatment. However, indications for PTES have been increasing in recent years. PTES has been recommended as a beneficial alternative to open decompression surgery in specific LRS cases; PTES is termed as percutaneous endoscopic ventral facetectomy (PEVF) in such cases. METHODS: In total, 65 elderly patients with LRS were prospectively studied. Patients presented severe comorbidities (coronary insufficiency, heart failure, diabetes mellitus, and respiratory failure); thus, general anesthesia administration would potentially cause considerable hazards. All the patients underwent successful PEVF in 2015–2016. The patients were assessed preoperatively and at 6 weeks; 3, 6, and 12 months; and 2 years postoperatively. Patients’ objective assessment was conducted according to specific clinical scales; the Visual Analog Scale (VAS) was separately used for leg and low-back pain (VAS-LP and VAS-BP, respectively), whereas the Short Form 36 Health Survey Questionnaire was used for the HRQoL evaluation. RESULTS: All studied parameters presented maximal improvement at 6 weeks postoperatively, with less enhancement at 3 and 6 months with subsequent stabilization. Statistical significance was found in all follow-up intervals for all parameters (p<0.05). Parameters with maximal absolute amelioration were VAS-LP, bodily pain, and role limitations due to physical health problems. In contrast, VAS-BP, general health, and mental health were comparatively less enhanced. CONCLUSIONS: PEVF was associated with remarkably enhanced HRQoL 2 years postoperatively. PEVF is thus a safe and effective alternative for LRS surgical management in elderly patients with severe comorbidities.

Comparison of Surgical Results between Soft Ruptured Disc and Foraminal Stenosis Patients in Posterior Cervical Laminoforaminotomy / 대한신경손상학회지

OBJECTIVE: Posterior cervical laminoforaminotomy is used to relieve cervical nerve root compression caused by a laterally herniated soft cervical disc or spondylotic spur and its several advantages and disadvantages compared with anterior cervical discectomy were reported. We compared surgical results between soft ruptured disc and foraminal stenosis in posterior cervical laminoforaminotomy. METHODS: We performed a retrospective review of 47 patients performed single level posterior cervical laminoforaminotomy for cervical radiculopathy between 2004 and 2012. We divided these patients into two groups, Group A: 27 patients for ruptured disc and Group B: 20 patients for foraminal stenosis and analyzed the demographic factors, amount of medial facetectomy, postoperative instability with neck pain and clinical outcomes. RESULTS: According to the modified Odom's criteria, laminoforaminotomy for the ruptured disc showed 92.6% excellent results and 7.4% good results. For the foraminal stenosis, it was 55.0% excellent and 25.0% good results, which was statistically significant. However when both groups were included, overall success rate showed 91.5%. The extent of medial facetectomy for ruptured disc (31.2%) was smaller than for stenosis (48.8%) and it was statistically significant. Thirteen patients complained of postoperative neck pain for 2 months. There was no instability on dynamic X-ray until the last follow up period and we had two cases complications (4.3%). CONCLUSION: Although the extent of facetectomy for ruptured disc was smaller than it for stenosis, posterior laminoforaminotomy for the ruptured disc showed the better outcomes than foraminal stenosis.

Morphometric Study of the Nerve Roots Around the Lateral Mass for Posterior Foraminotomy

OBJECTIVE: Morphometric data on dorsal cervical anatomy were examined in an effort to protect the nerve root near the lateral mass during posterior foraminotomy. METHODS: Using 25 adult formalin-fixed cadaveric cervical spines, measurements were taken at the lateral mass from C3 to C7 via a total laminectomy and a medial one-half facetectomy. The morphometric relationship between the nerve roots and structures of the lateral mass was investigated. Results from both genders were compared. RESULTS: Following the total laminectomy, from C3 to C7, the mean of the vertical distance from the medial point of the facet (MPF) of the lateral mass to the axilla of the root origin was 3.2-4.7 mm. The whole length of the exposed root had a mean of 4.2-5.8 mm. Following a medial one-half facetectomy, from C3 to C7, the mean of the vertical distance to the axilla of the root origin was 2.1-3.4 mm, based on the MPF. Mean vertical distances from the MPF to the medial point of the root that crossed the inferior margin of the intervertebral disc were 1.2-2.7 mm. The mean distance of the exposed root was 8.2-9.0 mm, and the mean angle between the dura and the nerve root was significantly different between males and females, at 53.4-68.4degrees. CONCLUSION: These data will aid in reducing root injuries during posterior cervical foraminotomy.

Prognosis and Necessity of Fixation in the Recurrent Lumbar Disc Herniation

OBJECTIVE: The fusion procedure can be an option on reoperative HNP cases. It is done routinely or on case-by-case basis. There have been no clear guideline and results about the instability rate that really needs fusion procedure. This study is done to clarify the need of fusion procedure and prognosis in the reoperation of lumbar disc herniation by regarding stability rate. METHODS: Total 27 cases with reoperative lumbar disc surgery were reviewed. Instability was tested preoperatively with X-ray findings which method was proposed by Dupuis in 1976. All operative procedures were done under microscopic magnification. The laminectomy and facetectomy amount was measured by the difference between the pre and postoperative X-ray findings. The stability test and final outcome were rated at least 6 months after the reoperation. The final results were categorized into excellent, good, fair, poor group according to the back, leg pain, walking ability, restriction of average daily life and use of analgesics. RESULTS: The average translation were 4.95%(flexion) with 5.04%(extension) for lumbar joints and 3.39%(flexion) with 4.17%(extension) for lumbosacral junction. Average flexion angulation were -2.3degrees for lumbar joints and 9.1degrees for lumbar sacral junction. The average amount of removed facet joint was 10.2%. Average 68.1% of facet joint remains after the reoperation. CONCLUSION: Fusion procedure is needed only in limited cases of recurrent disc herniation for the reason of possible instability. Routine fusion procedure should be avoided regarding stability problem. In literatures, the fusion rates shows extreme ranges from 0 to 100 % according to the authors. The prognosis was comparable with previous reports where most of the average good or excellent outcomes were ranging 60~70% of the cases without fusion procedures.

Effects of unilateral graded facetectomy on lumbar spinal stability / 第三军医大学学报

Objective To study the effects of unilateral graded facetectomy on lumbar spinal stability in biomechanics and to investigate the biomechanical characteristics of articular process and the safety of decompression produre for lumbar disc herniation.Methods The vertebral column L4/5 function spinal unit(FSU) of 5 adult cadavers was used and graded facetectomy was performed on left articular process of L4/5 resulting in 0,1/4,1/2,3/4,4/4 facetectomy of lateral small vertebral joints.The stability of each model was determined using three-dimension movement test machine of vertebral column.Results When more than 1/2 facetectomy of lateral small vertebral joints was carried out,the circuitation stability of left,right lateral flexion and the left,right axial direction of vertebral column and that of normal vertebral column had significant difference(P

Conjoined Nerve Root Anomaly Associated with Lumbar Disc Herniation: A Case Report

The condition of anomalous nerve root is rare. The authors are reporting a case of conjoined nerve root anomaly associated with lumbar disc herniation in a 36-year-old male who was transferred from another hospital. A standard hemilaminectomy with a discectomy had been performed under the disgnosis of the L4-5 lumbar disc herniation at the other hospital. However symptoms were not relieved. During a second surgery at our hospital, a L5-S1 conjoined nerve root was discovered after removal of the extradural hematoma at the previous laminectomy site, a medial facetctomy with a foraminotomy were carried out and the conjoined root was decompressed completely. The patient returned to work 2 months postoperatively with complete relief of symptoms.

Three Cases of Ossification of Ligamentum Flavum Causing Thoracic Myelopathy

The authors report three cases of ossification of ligamentum flavum causing thoracic myelopathy. The symptoms of all cases were numbness in the legs and feet and motor weakness. Preoperative diagnosis were simple spine X-ray, metrizamide CT and magnetic resonance imaging. There was satisfactory improvement in all cases after total laminectomy and medial facetectomy.

Myelopathy due to Ossification of Ligamentum Flavum

The 4 cases of myelopathy due to ossification of the ligamentum flavum are reported. This disease is often misdiagnosed by the central disc herniation, cauda equina tumor or lower motor neuron disease. The most useful diagnostic procedure is the computerized tomographic myelopgraphy. The sufficient decompressive laminectomy and facetectomy is a treatment of choice.

Far Lateral Lumbar Disc Herniation at L5-S1 Intervertebral Space: Case Report

One case of far lateral lumbar disc herniation(FLLDH) at left L5-S1 intervertebral space is reported. The herniation of disc material was localized mainly beyond the intervertebral foramen. Metrizamide myelogram was normal and only spine CT scan revealed the protruded disc material compressing the upper root inside and outside of the intervertebral foramen. Accordingly, the presenting symptoms and signs were due to left L5 root compression. Facetectomy was followed by removal of the herniated disc material. The patient was improved well.