Therapeutic Feasibility of Full Endoscopic Decompression in One- to Three-Level Lumbar Canal Stenosis via a Single Skin Port Using a New Endoscopic System, Percutaneous Stenoscopic Lumbar Decompression

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Although lumbar stenosis was recognized as a contraindication for endoscopic spine surgery in the past, the advancement in endoscopic system design and development of approach techniques and strategies now enabled the endoscopic spine surgeons to manage all types of lumbar stenosis safely and more effectively. A full-endoscopic lumbar technique for surgical management of spinal canal stenosis is now used today in many advanced spine centers around the world as one of their standard procedures which can be done under general, regional, local anesthesia with sedation. In this technical report, we described in detail the inside-out approach of performing lumbar endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD) and retrospectively reviewed hospital records of 127 patients who underwent the approach from December 2018 to March 2019 to address 1 level lumbar spinal stenosis and determined its outcome after 12-month follow-up period. Perioperative outcomes, operation time, length of hospital stay, and surgical complications were recorded and analyzed. The cross-sectional area of the thecal sac at the operated level was measured. The visual analogue scale (VAS) was assessed preoperatively, 1 month, and 12 months as well as the Oswestry Disability Index (ODI). The data were statistically analyzed (using SPSS ver. 17.0). The inside-out approach LE-ULBD was shown to effect statistically significant improvement in the VAS of leg and back pain as well as the ODI. It is a familiar, safe, and effective way of performing spinal stenosis decompression with good reproducible outcomes.

Section: Rationale Of the Inside-out Approachmentioning

confidence: 76%

Section: Introductionmentioning

confidence: 99%

Inside-Out Approach of Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: A Detailed Technical Description, Rationale and Outcomes

Lim¹,

Meceda

Park³

2020

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“…In the authors' opinion, the style used in the literature for interlaminar endoscopic decompression for spinal stenosis can be further divided into inside-out, outside-S100 www.e-neurospine.org in technique and contralateral approach. [8][9][10] The outside-in technique of decompression is what is described as over the top decompression in minimally invasive literature for both microscopic and endoscopic surgery. [11][12][13] The authors defined outsidein technique of endoscopic stenotic decompression as bony decompression of cephalad lamina, caudal lamina, inferior articular process, and superior articular process ("outside") to the extent that is sufficient for complete release of ligamentum flavum prior to removal of ligamentum en bloc with blunt instrument in the last part of the procedure to expose the spinal canal ("in").…”

Section: Introductionmentioning

confidence: 99%

“…The inside-out technique, on the other hand, involved bony decompression of lamina, inferior articular process, and superior articular process with early splitting of ligamentum flavum to get into spinal canal ("inside") prior to releasing ligamentum flavum from within the spinal canal with concurrent bony decompression ("out"). 10 Contralateral appro ach involved sparing ipsilateral ligamentum flavum and bony structure, creating sublaminar window working space in the contralateral lamina and performing contralateral ligamentum flavum resection and foraminotomy. 8,9,14,15 This review focus on LE-ULBD outside-in approach which is commonly known as over the top decompression technique.…”

Section: Introductionmentioning

confidence: 99%

Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression Outside-In Approach: A Proctorship Guideline With 12 Steps of Effectiveness and Safety

Kim

Jang

2020

Minimally invasive spinal surgery in particular lumbar endoscopic unilateral laminotomy with bilateral decompression becomes popular as it can be performed with regional anesthesia, soft tissue damages are minimized as endoscopic visualization and instruments can be brought close to operating area bypassing much of the intervening soft tissues for sufficient spinal decompression with ligamentum flavum resection despite less bony resection compared to open surgery. Overall, when well executed, it preserves spinal stability. Outside-in technique of decompression is also known as over the top decompression in minimally invasive literature. It involves maintaining deep layer of ligamentum flavum integrity till satisfactory bony decompression is achieved. Deep layer of ligamentum flavum is removed as final step of decompression. Preservation of the deep layer of ligamentum flavum protects the neural elements, allowing drills and sharp equipment to be used safely to perform bony decompression.In this study, we demonstrate the technical details of outside-in approach lumbar endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD). LE-ULBD Outside-in Technique is an effective and safe procedure in relieving lumbar spinal stenosis with favorable results with a follow-up for more than 1 year.

“…In recent years, endoscopic decompression surgery has been used to treat central canal stenosis 7 and other kinds of lumbar degenerative stenosis using newly designed endoscopes, with shorter and wider working channels, and surgical tools. 8 The route approaching down from the skin via the lamina to the epidural space is anatomically more familiar to most spine surgeons than the I-O technique in ETD. However, not a few endoscopic spine surgeons, including Yeung, still place a high value on I-O taking the foraminal route and insist that the ETD might be used for most lumbar spine pathologies, except for those that are unreachable.…”

mentioning

confidence: 99%

Inside-Out and Outside-In Techniques in Endoscopic Spine Surgery: Are These Techniques Efficient Even for Pathology Irrelevant to the Intervertebral Foramen?

Park¹

2020

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Inside-out (I-O)"-this simple phrase, which Yeung introduced in the 1990s, has become one of the standard terms used by endoscopic spine surgeons. 1 Furthermore, the I-O technique has become a fundamental and popular technique in endoscopic transforaminal discectomy and decompression (ETD). The I-O technique enables better visualization of intradiscal conditions that cause pain, enabling the surgeon to perform intradiscal therapy. A comparative study 2 in foraminal stenosis demonstrated that I-O had better long-term results at a 5-year follow-up than the outside-in (O-I) technique. Yeung and Lewandrowski 2 argued that the better outcomes of I-O were brought about by additional intradiscal therapy during the early stage of an operation. However, the therapeutic effect of intradiscal treatment on backache when the I-O technique is used exceeds the scope of the current discussion. These techniques are mainly designated for the endoscopic management of pathology through the intervertebral foramen. There is no accessible route other than the through the foramen to approach pathology in the vertebral canal without laminectomy. Both techniques use a posterior and lateral incision from the midline of the back for skin access. The I-O technique is started by placing an endoscope in the disc, while the first step in the O-I technique is localizing the foramen for foraminoplasty. In the final stage, the I-O technique leads to a widened foramen by successive decompressions. 2 In contrast, the O-I technique results in free nerve roots by decompression in the last endoscopic view. 3 According to these descriptions, I-O and O-I are surgical techniques for pathologies that are only accessible through the intervertebral foramen. I read 2 articles dealing with I-O and O-I in the management of endoscopic decompression that were published in this special issue. 4,5 These cases seemed to emulate Yeung's concept when describing their endoscopic approach to a lesion. However, I did not find any critically different points, especially in the techniques used for the approach, between the 2 groups. They might not have a significant enough difference from each other for it to be appropriate to use different terminology. If pressed to find a difference between the techniques in these manuscripts, I might point out that they differ in terms of how to remove the ligamentum flavum (as a whole or piecemeal). In the article using the O-I technique, 4 the author indicated that the O-I technique performed in their study was similar to "the over-the-top" technique. 6 Using scientific termi