Patient selection protocols for endoscopic transforaminal, interlaminar, and translaminar decompression of lumbar spinal stenosis.

BACKGROUND: The indications of different endoscopic and endoscopically assisted translaminar approaches for lumbar spinal stenosis are not well-defined, and validated protocols for the use of the transforaminal over the interlaminar approach are lacking. METHODS: We performed a retrospective study employing an image-based patient stratification protocol of stenosis location (type I-central canal, type II-lateral recess, type III-foraminal, type IV-extraforaminal) and clinical outcomes on 249 patients consisting of 137 (55%) men and 112 (45%) women with an average age of 56.03±16.8 years who underwent endoscopic surgery for symptomatic spinal stenosis from January 2013 to February 2019. The average follow-up of 38.27±27.9 months. The primary clinical outcome measures were the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), and modified Macnab criteria. RESULTS: The frequency of stenosis configuration in decreasing order was as follows: type I-121/249; 48.6%, type III-104/249; 41.8%, type II-15/249; 6%, and type IV-9/249; 3.6%. The transforaminal approach (137/249; 55.0%) was used in most type II to IV lesions followed by the interlaminar approach (78/249; 31.3%), and the full endoscopic approach (12/249; 4.8%), and the endoscopically assisted translaminar approach (8/249; 3.2%) which was exclusively used for type I lesions. Macnab outcomes analysis showed Excellent in 47 patients (18.9%), Good in 178 (71.5%), Fair in 18 (7.2%) and Poor in 6 (2.4%), respectively. Paired two-tailed t-test showed statistically significant VAS (5.46±2.1; P<0.0001) and ODI (37.1±16.9; P<0.0001) reductions as a result of the endoscopic decompression surgery. Cross-tabulation of the Macnab outcomes versus the endoscopic approach and surgical technique confirmed beneficial association of the approach selection with Excellent (P=0.001) and Good (P<0.0001) outcomes with statistically significance. CONCLUSIONS: This study suggests that in the hands of skilled endoscopic spines surgeon use of an image-based stenosis location protocol may contribute to obtaining Excellent and Good clinical outcomes in a high percentage (93%) of patients suffering from lumbar stenosis related radiculopathy. Additional comparative studies should examine the prognostic value of choosing the endoscopic approach on the basis of the proposed four-type stenosis protocol by correlating its impact on outcomes with preoperative diagnostic injections and intraoperative direct visualization of symptomatic pain generators under local anesthesia and sedation.

Liberación endoscópica del túnel cubital. Técnica y resultados clínico-funcionales / Endoscopic release of the ulnar tunnel. Technique and clinical-functional outcomes

Resumen: Introducción: El síndrome del túnel cubital es la segunda neuropatía por compresión de la extremidad superior, seguido del síndrome del túnel del carpo, por lo que es un motivo de consulta frecuente dentro de la cirugía de mano. Existen pocos estudios publicados acerca de la técnica endoscópica. Material y métodos: Se incluyeron 26 pacientes con el diagnóstico clínico y electromiográfico de síndrome de túnel cubital, en quienes se realizó liberación endoscópica del túnel cubital. Nueve (35%) fueron mujeres y 17 (65%) hombres. Se utilizó la clasificación de McGowan modificada y la clasificación de Wilson y Krout para analizar las características de las variables en su estado prequirúrgico y postquirúrgico. Resultados: Posterior a la intervención, obtuvimos 18 pacientes (69%) con resultado excelente, seis (24%) con un buen resultado y dos (7%) con resultados regulares o aceptables, obteniendo una p significativa con un valor < 0.05. Conclusión: La liberación endoscópica del túnel cubital se considera una técnica segura, con buenos resultados.

Abstract: Introduction: The ulnar tunnel syndrome is the second compressive neuropathy, followed by the carpal tunnel, making it a frequent reference in hand surgery. There are few published studies about endoscopic technique. Material and methods: We studied 26 patients with ulnar tunnel syndrome diagnosis, were operated by endoscopic release of the ulnar tunnel. Nine women (35%) and 17 (65%) male patients. We used the modified McGowan, and the Wilson and Krout classification to analyze preoperative and postoperative variables. Results: After endoscopic decompression we obtained 18 patients (69%) with excellent evolution, 6 (24%) with good evolution, and 2 (7%) with acceptable outcome. We obtained a significant p of < 0.05. Conclusion: Endoscopic decompression of the ulnar tunnel is a safe technique, less invasive and with good outcome.

[Endoscopic release of the ulnar tunnel. Technique and clinical-functional outcomes]. / Liberación endoscópica del túnel cubital. Técnica y resultados clínico-funcionales.

INTRODUCTION: The ulnar tunnel syndrome is the second compressive neuropathy, followed by the carpal tunnel, making it a frequent reference in hand surgery. There are few published studies about endoscopic technique. MATERIAL AND METHODS: We studied 26 patients with ulnar tunnel syndrome diagnosis, were operated by endoscopic release of the ulnar tunnel. Nine women (35%) and 17 (65%) male patients. We used the modified McGowan, and the Wilson and Krout classification to analyze preoperative and postoperative variables. RESULTS: After endoscopic decompression we obtained 18 patients (69%) with excellent evolution, 6 (24%) with good evolution, and 2 (7%) with acceptable outcome. We obtained a significant p of 0.05. CONCLUSION: Endoscopic decompression of the ulnar tunnel is a safe technique, less invasive and with good outcome.

INTRODUCCIÓN: El síndrome del túnel cubital es la segunda neuropatía por compresión de la extremidad superior, seguido del síndrome del túnel del carpo, por lo que es un motivo de consulta frecuente dentro de la cirugía de mano. Existen pocos estudios publicados acerca de la técnica endoscópica. MATERIAL Y MÉTODOS: Se incluyeron 26 pacientes con el diagnóstico clínico y electromiográfico de síndrome de túnel cubital, en quienes se realizó liberación endoscópica del túnel cubital. Nueve (35%) fueron mujeres y 17 (65%) hombres. Se utilizó la clasificación de McGowan modificada y la clasificación de Wilson y Krout para analizar las características de las variables en su estado prequirúrgico y postquirúrgico. RESULTADOS: Posterior a la intervención, obtuvimos 18 pacientes (69%) con resultado excelente, seis (24%) con un buen resultado y dos (7%) con resultados regulares o aceptables, obteniendo una p significativa con un valor 0.05. CONCLUSIÓN: La liberación endoscópica del túnel cubital se considera una técnica segura, con buenos resultados.

Readmissions After Outpatient Transforaminal Decompression for Lumbar Foraminal and Lateral Recess Stenosis.

BACKGROUND: The objective of this study was to analyze readmission rates after outpatient transforaminal endoscopic decompression surgery for lumbar foraminal and lateral recess stenosis done in an ambulatory surgery center. Endoscopic lumbar spinal surgery is gaining popularity for the treatment of lumbar disc herniations. Recent advances in surgical techniques allow for percutaneous endoscopically assisted bony decompression for neurogenic claudication symptoms due to spinal stenosis. The surgery can be done under local anesthesia and sedation. Patients may be discharged home within hours from surgery, and complications are rare. However, readmissions for recurrent disc herniations, failure of pain relief, dysesthetic leg pain, nerve root injuries with foot drop, and facet and pedicle fractures have been reported. METHODS: A retrospective study of 1839 consecutive patients with an average mean follow up of 33 months (range 24 to 85 months) that underwent percutaneous endoscopic surgery at 2076 levels between 2006 and 2015 was conducted with the intent of identifying factors associated with emergency room or hospital readmission following endoscopic foraminotomy and microdiscectomy. Only patients with unilateral radiculopathy due to either herniated disc or lateral recess stenosis were included in this study. Preoperatively, disc migration was graded by direction and distance from the disc space according to Lee's radiologic 4-zone classification. The type of disc herniation was classified either as extruded or contained. Contained herniations were further subclassified as disc protrusions versus disc bulges. In addition, the preoperative disc height was recorded. Bony spinal foraminal stenosis and lateral recess stenosis were graded on preoperative magnetic resonance imaging and computed tomography scans into mild, moderate, and severe by dividing the lumbar neuroforamen into 3 zones: (a) entry zone, (b) midzone, and (c) exit zone. Surgical outcomes were classified according to the Macnab criteria. In addition, reduction in visual analog scores (VASs) were assessed. The treating physician (KUL) performed all surgeries. RESULTS: According to the Macnab criteria, excellent and good results were obtained in 82.2% of patients with extruded disc fragment (331/1839). In this group, the mean VAS decreased from 5.9 ± 2.5 preoperatively to 2.4 ± 1.8 at the final follow up (P < .01). Patients with contained disc herniations (648/1839) had excellent and good results 72.7% of the time. In this group, the mean VAS decreased from 7.2 ± 1.6 preoperatively to 3.1 ± 1.5 at the final follow up (P < .01). In the spinal stenosis group (860/1839), 75% of patients had excellent to good results. There were no major approach-related complications. Sixty-nine patients had extravasations of irrigation fluid into the subcutaneous tissues (3.8%). Eight patients developed spinal headaches (0.4%). Two patients developed foot drop on the surgical side immediately postoperatively (0.1%). Reherniations of extruded discs occurred in 9 patients (2.7% recurrence rate). Failure of pain relief without significant improvement of walking endurance occurred in 29 patients with bony stenosis in the central canal, lateral recess, and entry zone of the neuroforamen (3.3%). Reherniations were associated with preserved disc height of >6 mm (P < .02). Dysesthetic leg pain due to dorsal root ganglion irritation occurred in 229 patients (12.4%) and was unrelated to case frequency but was associated with severe foraminal stenosis (P < .01). All 229 patients improved with supportive care. Facet or pedicle fractures did not occur in this series. There were 26 acute care (within 6 weeks from surgery) postoperative emergency room visits [16 of which resulted in readmission to a hospital over the 9-year study period (0.86%): 9 for dysesthetic leg pain, 2 for wound infections, and 5 for poorly controlled incisional pain]. CONCLUSIONS: Transforaminal endoscopic decompression can be successfully carried out in an outpatient surgery center setting. Readmissions due to reherniations, postoperative complications, or poor pain control are uncommon.

Minimally invasive endoscopic decompression for anterior interosseous nerve syndrome: technical notes.

Anterior interosseous nerve syndrome (Nevin-Kiloh syndrome) is a rare entity caused by compression of the purely motor anterior interosseous nerve in the forearm. Historically, conventional surgical treatment has consisted of open decompression of the nerve. Unfortunately, open decompression is often complicated by scarring and significant morbidity. Endoscopic decompression is an alternative means of surgical intervention in the hands of well-trained surgeons comfortable with soft tissue endoscopy. In this report, we review relevant anatomy, offer technical hints, and present our personal experience with 4 illustrative cases, all with greater than 1.5 years of follow-up. Our patients showed considerable improvement of their symptoms with minimal scarring. No significant complications occurred.