Transforaminal Endoscopic Lumbar Decompression & Foraminoplasty: A 10 Year prospective survivability outcome study of the treatment of foraminal stenosis and failed back surgery

Abstract

BackgroundConventional diagnosis between axial and foraminal stenosis is suboptimal and long-term outcomes limited to posterior decompression. Aware state Transforaminal Endoscopic Lumbar Decompression and Foraminoplasty (TELDF) offers a direct aware state means of localizing and treating neuro-claudicant back pain, referred pain and weakness associated with stenosis failing to respond to conventional rehabilitation, pain management or surgery. This prospective survivability study examines the outcomes 10 years after TELDF in patients with foraminal stenosis arising from degeneration or failed back surgery.MethodsFor 10 years prospective data were collected on 114 consecutive patients with multilevel spondylosis and neuro-claudicant back pain, referred pain and weakness with or without failed back surgery whose symptoms had failed to respond to conventional rehabilitation and pain management and who underwent TELDF. The level responsible for the predominant presenting symptoms of foraminal stenosis, determined on clinical grounds, MRI and or CT scans, was confirmed by transforaminal probing and discography. Patients underwent TELDF at the spinal segment at which the predominant presenting symptoms were reproduced. Those that required treatment at an additional segment were excluded. Outcomes were assessed by postal questionnaire with failures being examined by the independent authors using the Visual Analogue Pain Scale (VAPS), the Oswestry Disability Index (ODI) and the Prolo Activity Score.ResultsCohort integrity was 69%. 79 patients were available for evaluation after removal of the deceased (12), untraceable (17) and decliners (6) from the cohort.VAP scores improved from a pre-operative mean of 7.3 to 2.4 at year 10. The ODI improved from a mean of 58.5 at baseline to 17.5 at year 10. 72% of reviewed patients fulfilled the definition of an “Excellent” or “Good Clinical Impact” at review using the Spinal Foundation Outcome Score. Based on the Prolo scale, 61 patients (77%) were able to return and continue in full or part-time work or retirement activity post-TELDF. Complications of TELDF were limited to transient nerve irritation, which affected 19% of the cohort for 2 – 4 weeks. TELDF was equally beneficial in those with failed back surgery.ConclusionsTELDF is a beneficial intervention for the long-term treatment of severely disabled patients with neuro-claudicant symptoms arising from spinal or foraminal stenosis with a dural diameter of more than 3mm, who have failed to respond to conventional rehabilitation or chronic pain management. It results in considerable improvements in symptoms and function sustained 10 years later despite co-morbidity, ageing or the presence of failed back surgery.Clinical RelevanceThe long term outcome of TELDF in severely disabled patients with neuro-claudicant symptoms arising from foraminal stenosis which had failed to respond to conventional rehabilitation, surgery or chronic pain management suggests that foraminal pathology is a major cause of lumbar axial and referred pain ...

Transforaminal Endoscopic Discectomy and Foraminoplasty for Treating Central Lumbar Stenosis

“…Two weeks after the treatment with oral neurotrophic drugs and nonsteroidal anti‐inflammatory therapy, the symptoms were completely relieved. Knight et al . reported that transient post‐operative “flares” were noted in 19% of cases.…”

“…first described the transforaminal arthroscopic decompression of lateral recess stenosis in 1996. In 2014, Knight et al . and Lewandrowski described PTED is a beneficial intervention for the treatment of spinal or foraminal stenosis.…”

Modified Percutaneous Lumbar Foraminoplasty and Percutaneous Endoscopic Lumbar Discectomy: Instrument Design, Technique Notes, and 5 Years Follow-up

“…Endoscopic foraminoplasty with a side-firing laser, high-speed burr, trephine, or reamer, etc. has been proven to be a safe procedure to widen the lumbar foramen by removing part of bone and ligamentous tissue surrounding the foramen (17,(24)(25)(26)(27)(28). However, the disadvantages of endoscopic foraminoplasty are quite obvious, for example, expensive equipment, low working efficiency, inadequate decompression for lateral recess stenosis, and risk of heat-damage to surrounding spinal nerves (11,12,15,16).…”

“…Besides, the increase in temperature while using a highspeed burr or side-firing laser may potentially lead to inflammation of the nerve and may also cause deterioration of nerve conduction to some extent (15,16). Knight et al (17) reported that transient post-operative "flares" were noted in 19% of patients when a sidefire laser was used in transforaminal endoscopic lumbar foraminoplasty for foraminal stenosis, while Ahn et al (18) reported 6.1% postoperative dysesthesia after endoscopic foraminotomy with an endoscopic high-speed drill. The disadvantages of endoscopic foraminoplasty also include a steep learning curve and need of expensive equipment.…”

Morphometric Changes of the Lumbar Intervertebral Foramen after Percutaneous Endoscopic Foraminoplasty under Local Anesthesia

“…There were no permanent complications, but temporary dysesthesia indicated irritation of the DRG. Knight et al 29 reported that transient postoperative "flares" were noted in 15 (19%) of 79; they were a transient recurrence of the patient's predominant presenting symptoms beginning a week after surgery and lasting 2 to 4 weeks. Theoretically, nerve compression injury is likely to occur if the 8-mm cannula is inserted in the very narrow intervertebral foramen.…”