Transforaminal Endoscopic Lateral Recess Decompression

Yutaro Kanda; Saori Soeda; Ryota Mio; Fumiaki Makiyama; Masatoshi Morimoto; Fumitake Tezuka; Kazuta Yamashita; Koichi Sairyo

doi:10.21182/jmisst.2024.01550

Video

Journal of Minimally Invasive Spine Surgery and Technique 2024; 9(2): 190-192.

Published online: October 31, 2024

DOI: https://doi.org/10.21182/jmisst.2024.01550

Transforaminal Endoscopic Lateral Recess Decompression

Yutaro Kanda^1,²

, Saori Soeda¹

, Ryota Mio¹

, Fumiaki Makiyama¹

, Masatoshi Morimoto¹

, Fumitake Tezuka¹

, Kazuta Yamashita¹

, Koichi Sairyo¹

¹Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan

²Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan

Corresponding Author: Koichi Sairyo Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan Email: sairyokun@gmail.com

Received June 26, 2024 Accepted July 22, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Transforaminal full-endoscopic spine surgery (TF-FESS) is a minimally invasive surgical procedure that can be performed with only an 8-mm skin incision under local anesthesia. TF-FESS has been used to treat not only lumbar disc herniation, but also lumbar spinal stenosis. This paper describes transforaminal full-endoscopic lateral recess decompression. The best indication for this procedure is unilateral recess stenosis accompanied by transversing nerve root radiculopathy, with or without exiting nerve root radiculopathy. The skin entry point is about 6–8 cm from the midline, and the precise point is determined by preoperative planning. After local anesthesia, an 8-mm skin incision is made, and the cannula is placed on the surface of the superior articular process (SAP). Next, the SAP is resected from the pedicle to the tip using a high-speed drill to expose the facet joint space and flavum by the hand-down technique (gradually changing hand position to be downwards and moving the cannula inwards). After removing the flavum, the completely decompressed transversing nerve root can be clearly visualized and confirmed under fluoroscopy. Two hours postoperatively, patients can walk without restriction. Because this procedure requires the complete resection of the ventral side of the facet, it is also called full-endoscopic ventral facetectomy.

Key Words: Full-endoscopic spine surgery, Lateral recess decompression, Ventral facetectomy, Local anesthesia.

WRITTEN TRANSCRIPT

0:00 Transforaminal Endoscopic Lateral Recess Decompression

I am going to demonstrate our procedure for transforaminal endoscopic lateral recess decompression [1-8].

0:10 Case

A 70-year-old woman was referred to our hospital with left leg pain and intermittent claudication that was resistant to conservative treatment for 2 years.

0:26 Physical and Neurological Examination

She had left L5 radicular pain and mild muscle weakness of the tibialis anterior and extensor hallucis longus.

0:36 Radiographs

Radiographs showed lumbar degenerative scoliosis.

0:44 Magnetic Resonance Imaging

Magnetic resonance imaging revealed L5 nerve root entrapment at the lateral recess at L4–5 level without L5–S foraminal stenosis.

0:57 Preoperative Preparation With Computed Tomography

Using preoperative computed tomography imaging, we planned discography and initial cannula placement. We also planned resection of the superior articular process (SAP).

1:12 Local Anesthesia

For local anesthesia, 1% lidocaine was injected into the skin and subcutaneous tissue around the insertion point and trajectory. Next, we also injected 1% lidocaine into the facet, tip and base of the SAP and the pedicle using a percutaneous transhepatic cholangial drainage needle using the “walking technique.” Then, 1% lidocaine was injected into the annulus fibrosus. A mixture of contrast media and dye with 1% lidocaine was injected into the nucleus pulposus.

1:57 Cannula Placement

An 8-mm skin incision was made. The dilators and cannula were inserted over the needle under fluoroscopic guidance while taking care not to injure the exiting nerve root. The cannula is usually placed on the lateral surface of the SAP.

2:19 Identification of the SAP

To ensure visibility and orientation, we exposed the lateral surface of the SAP using radiofrequency energy.

3:02 Resection of SAP Using a High-Speed Drill

Next, we resected the SAP from the base to the tip using a high-speed drill to expose the flavum and facet joint.

3:58 Identification of SAP-Pedicle Junction

We could confirm the SAP-pedicle junction where it was not surrounded by flavum.

4:27 Decompression of the Transversing Nerve Root

Further resection of the SAP and partial resection of inferior articular process promoted detachment of the flavum. After removal of the flavum using a rongeur, we could see the pulsating transversing nerve root. Finally, excellent decompression was confirmed using a probe under fluoroscopy. The operation time was 50 minutes.

5:42 Successful Decompression

At 6 months after surgery, magnetic resonance imaging demonstrated excellent decompression of lateral recess. Her muscle weakness had resolved and the Visual Analogue Scale for left leg pain had decreased from 6 to 0.

NOTES

Conflict of Interest

KS, a member of the Editorial Board of Journal of Minimally Invasive Spine Surgery & Technique, is the corresponding author of this article. However, he played no role whatsoever in the editorial evaluation of this article or the decision to publish it. Author has no conflict of interest to declare.

Funding/Support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Informed Consent

Written informed consent was obtained from the patient in accordance with the principles of the Declaration of Helsinki and the laws and regulations of Japan.

REFERENCES

1. Kerimbayev T, Kenzhegulov Y, Tuigynov Z, Aleinikov V, Urunbayev Y, Makhambetov Y, et al. Transforaminal endoscopic discectomy under general and local anesthesia: a single-center study. Front Surg 2022;9:873954.

2. Choi I, Ahn JO, So WS, Lee SJ, Choi IJ, Kim H. Exiting nerve root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety. Eur Spine J 2013;22:2481–7.

3. Sairyo K, Chikawa T, Nagamachi A. State-of-the-art transforaminal percutaneous endoscopic lumbar surgery under local anesthesia: discectomy, foraminoplasty, and ventral facetectomy. J Orthop Sci 2018;23:229–36.

4. Sairyo K, Higashino K, Yamashita K, Hayashi F, Wada K, Sakai T, et al. A new concept of transforaminal ventral facetectomy including simultaneous decompression of foraminal and lateral recess stenosis: technical considerations in a fresh cadaver model and a literature review. J Med Invest 2017;64:1–6.

5. Kishima K, Yagi K, Yamashita K, Tezuka F, Morimoto M, Takata Y, et al. Transforaminal full-endoscopic ventral facetectomy: midterm results and factors associated with poor surgical outcomes. J Neurol Surg A Cent Eur Neurosurg 2024;85:155–63.

6. Wu PH, Kim HS, Jang IT. A narrative review of development of full-endoscopic lumbar spine surgery. Neurospine 2020;17(Suppl 1):S20–33.

7. Kapetanakis S, Gkantsinikoudis N, Papathanasiou JV, Charitoudis G, Thomaidis T. Percutaneous endoscopic ventral facetectomy: an innovative substitute of open decompression surgery for lateral recess stenosis surgical treatment? J Craniovertebr Junction Spine 2018;9:188–95.

8. Kapetanakis S, Gkantsinikoudis N, Charitoudis G. Full-endoscopic ventral facetectomy vs open laminectomy for lumbar lateral recess stenosis: a comparative study and brief literature review. Int J Spine Surg 2022;16:361–72.