Indications

Li, Zhen-Zhou

doi:10.1007/978-981-10-3905-8_11

Zhen-Zhou Li⁴

875 Accesses

Abstract

The indications for surgical treatment of lumbar intervertebral disc herniation under the percutaneous spinal endoscope are introduced in detail. A systematic introduction is made to the percutaneous endoscopic surgical technique selection for different types of lumbar disc herniation. Details of the percutaneous endoscopic surgical stratagy that should be used for various types and locations of lumbar spinal stenosis are also introduced. The indications and surgical techniques for the treatment of discopenic low back pain, chronic facet joint pain, and lumbar instability are also briefly introduced. The use of percutaneous endoscopic surgical techniques for the treatment of lumbar fractures, osteoid osteomas and other diseases is also forward-looking.

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Endoscopic spine discectomy: indications and outcomes

Article 05 January 2019

Endoscopic Percutaneous Discectomy

Full-Endoscopic Lumbar and Cervical Surgery for Disc Herniation

Percutaneous endoscopic procedures have been and are being employed predominantly for the treatment of lumbar disc herniation, lumbar spinal stenosis, degenerative facet joint cyst, degenerative chronic low back pain, etc.

1 Lumbar Disc Herniation

Herniation or protrusion of the gelatinous nucleus pulposus into or through the annulus fibrosus is a well-recognized cause of low back pain and sciatica. The goal of surgery for sciatica due to a disc herniation is to identify the offending fragment and remove it with as little damage to surrounding structures as possible. At the current level of surgical technique, almost all types of lumbar disc herniation can be treated with percutaneous endoscopic discectomy.

Locating the herniated disc (HD) position is critical to selecting the appropriate surgical technique. Based on axial MRI, MSU classification [1] (Fig. 11.1a–c) can be used to precisely position the herniated discs (HDs) in the axial plane. It is also necessary to determine the degree of migration of the HD on the sagittal MRI [2, 3] (Fig. 11.2a, b).

1.1 Far Lateral Lumbar Disc Herniation

The vast majority of far lateral lumbar disc herniation (MSU zone C) can be treated with percutaneous endoscopic discectomy through posterolateral approach or extraforaminal approach. First, the working cannula was inserted into the intervertebral disc through the safe triangular working zone, the loose and free intradiscal nucleus pulposus tissue was removed, and then the working cannula was retreated to the safe triangular working zone to explore and remove the prolapse of the nucleus pulposus (inside-outside technique) (Fig. 11.3).

For patient with nerve root anomalies or hypertrophy of articular processes, the effective safe triangular working zone is small and cannot accommodate the working cannula. The working cannula can be floated on the dorsal side of the exit nerve root and the prolapse of the nucleus pulposus be exposed and removed with endoscopic surgical tools. And then intradiscal free nucleus pulposus removed through safe triangle working zone (outside-inside technique) (Fig. 11.4).

Foraminoplasty can also be used to partially resect anterolateral bony structure of superior articular process so that the expansion of the external opening of the intervertebral foramen and the effective safe triangular working zone can be achieved for the docking of the working cannula, then the aforementioned inside-outside technique can be used to remove the intradiscal free nucleus pulposus and prolapse of the nucleus pulposus (inside-outside technique with foraminoplasty) (Fig. 11.5).

1.2 Intracanal Lumbar Disc Herniation

1.2.1 Transforaminal Approach

For contained intracanal lumbar disc herniation with MSU zone A-B and grade 1–2 limited at the level of intervertebral disc or low-grade migration, conventional percutaneous endoscopic lumbar discectomy (PELD) through posterolateral or far lateral approach is enough to remove the intradiscal free nucleus pulposus and prolapse of the nucleus pulposus [4, 5] (Fig. 11.6).

But conventional PELD with the “inside-outside technique ” has a 4.3–10.3% surgical failure rate, especially in central HDs, migrated HDs, and axillary type HDs [7]. PELD with foraminoplasty has been used for complex HDs. Foraminoplasty was defined as “widening of the foramen by undercutting of ventral part of the superior articular process (SAP) with ablation of the foraminal ligament, using bone trephines or an endoscopic drill and side-firing laser to visualize the anterior epidural space and its contents” [8].

For uncontained HDs or MSU grade 3 limited at the level of intervertebral disc or low-grade migration, foraminoplasty with partial resection of ventral bony structure of superior articular process should be adopted to ensure complete removal of herniated intervertebral disc tissue without omission [6] (Fig. 11.7).

For HDs with high-grade upward migration, foraminoplasty with resection of the tip of superior articular process should be adopted to ensure complete removal of herniated intervertebral disc tissue without omission (Fig. 11.8).

For HDs with very high-grade upward migration, foraminoplasty with partial resection of ventral bony structure of cephalad-vertebral isthmus should be adopted to ensure complete removal of herniated intervertebral disc tissue without omission (Fig. 11.9). In some cases, foraminoplasty through suprapedicle or transpedicle approach at the upper level might be combined (Fig. 11.10).

For HDs with high-grade or very high-grade downward migration, foraminoplasty through suprapedicular or transpedicular approach can ensure complete removal of HDs [9] (Fig. 11.11).

1.2.2 Interlaminar Approach

Before percutaneous endoscopic lumbar discectomy through interlaminar approach, the surgeon should precisely position the herniated disc. According to relationship between the herniated intervertebral disc and traversing nerve root, herniated discs can be divided into axilla type, ventral type, and shoulder type [10] (Fig. 10.40). The site where the traversing nerve root exits from the dura sac also should be carefully evaluated preoperatively, which may be located cephalad, parallel, or caudal to the intervertebral disc space [11].

For the ventral type or shoulder type herniated discs, removal of the intradiscal free nucleus pulposus and prolapse of the nucleus pulposus should be performed through shoulder approach (lateral to the traversing nerve root) [10] (Fig. 11.12).

For the axilla-type herniated discs with traversing nerve root exiting from dura sac cephala or parallel to the intervertebral space, axillary approach (between the traversing nerve root and dura sac) should be adopted to remove the prolapse of the nucleus pulposus and the intradiscal free nucleus pulposus simultaneously [10] (Fig. 11.13).

For the axilla-type herniated discs with traversing nerve root exiting from dura sac caudal to the intervertebral space, axillary approach should be adopted to remove the prolapse of the nucleus pulposus firstly and then shoulder approach adopted to remove the intradiscal free nucleus pulposus (Fig. 11.14).

2 Lumbar Spine Stenosis

Lumbar spinal stenosis is narrowing of the lumbar canal, causing compression of the dura sac and nerve roots. Spinal stenosis presents with radiculopathy, neurogenic claudication, or mechanical back pain. An extreme presentation of lumbar stenosis is cauda equina syndrome .

Stenosis may be present in the central canal, the lateral recess, and/or the intervertebral foramen. Decompressive surgery is recommended in patients with progressive neurological loss or patients whose quality of life is affected to a great extent. Wide laminectomies and facetectomies may provide permanent relief.

2.1 Intervertebral Foramen Stenosis

The intervertebral foramen is bordered superiorly by the inferior border of the pedicle above and inferiorly by the superior border of the pedicle below. Posterior borders include the pars, ligamentum, and the superior facet. Compression may arise from an intraforaminal disc protrusion or hypertrophy of the medial aspect of the superior facet (Fig. 11.15), or by a pars defect with fibrous overgrowth (Fig. 11.16). The foramen is further subdivided into the midzone and exit zones. The midzone contains the dorsal root ganglion (DRG) and ventral root, whereas the exit zone contains the peripheral nerve. Normal foraminal height is between 20 and 23 mm. Foraminal height less than 15 mm and posterior disc height less than 4 mm are associated with nerve root compression in 80% of patients [12,13,14].

Intervertebral foramen stenosis can be decompressed with percutaneous endoscopic procedures through ipsilateral transforaminal approach or contralateral interlaminar approach (Fig. 11.17). Hypertrophy of the superior facet, fibrous or cartilaginous overgrowth anterior to the pars defect, and/or intraforaminal disc protrusion can be resected endoscopically so that the release and decompression of the exiting nerve root can be achieved [15,16,17].

2.2 Lateral Recess Stenosis

The lateral recess is also known as the subarticular or entrance zone. It is bordered anteriorly by the posterolateral vertebral body and disc, posteriorly by the pars intercularis and ligamentum flavum, laterally by the superior facet, and medially by the inferior facet. The lateral recess is narrowest at the superior border of the corresponding pedicle. Normally, the lateral recess should be more than 5 mm in height. Relative stenosis is present if the lateral recess height is between 3 and 5 mm, and absolute lateral recess stenosis is present when the height is less than 3 mm [18, 19].

Lateral recess stenosis can be effectively decompressed with percutaneous endoscopic procedures through ipsilateral transforaminal approach [20] (Fig. 11.18), ipsilateral or contralateral interlaminar approach [21] (Fig. 11.19).

2.3 Central Canal Stenosis

The central canal is the region occupied by the dura sac. The lumbar central canal normally has a midsagittal diameter greater than 13 mm. Relative stenosis is defined as an anteroposterior (AP) canal diameter between 10 and 13 mm, and absolute stenosis is present when the AP canal diameter is less than 10 mm. The normal thecal sac measures 16–18 mm. The area of the normal sac should be more than 100 mm². When the sac is compressed to an area measuring between 76 and 100 mm², the compression is described as moderate stenosis. An area less than 76 mm² suggests severe spinal canal stenosis [22, 23].

Central canal stenosis can be effectively decompressed with percutaneous endoscopic procedures through bilateral transforaminal approach [20] (Fig. 11.20) or interlaminar approach [24] (Fig. 11.21). Percutaneous endoscopic bilateral decompression through unilateral interlaminar approach is another option for the treatment of lumbar central canal stenosis (Fig. 11.22).

3 Chronic Low Back Pain

Chronic low back pain lasts greater than 12 weeks. Spondylogenic pain originates in the spinal column and/or the associated soft tissues such as the intervertebral discs, facet joints, and paraspinal musculature. The buttock may also be the site of back-dominant pain since the buttock share the same segmental nerve supply with the lumbosacral regions (L4, L5, S1). The sinu-vertebral nerve innervates the posterior longitudinal ligaments, the ventral aspect of the dura sac, blood vessels, and the posterior part of the annulus fibrosis. Although the nucleus pulposus is not innervated, the superficial annular fibers are innervated by the sinu-vertebral nerve and branches of the lumbar ventral rami. Pressure on the posterior surface of the intervertebral disc or irritation of the superficial fibers of a herniated lumbar disc has been shown to elicit pain in the lumbosacral region or the ipsilateral hip and buttock. Lumbar facet joints are innervated by medial branches of the dorsal primary rami. Degenerative changes of the facet joints may lead to the development of two sources of pain: first, damage to the articular cartilage of the facet may lead to pain similar to osteoarthritis of any joint surface; and second, degenerative changes of the facet joint such as bony overgrowth and osteoarthritis may lead to nerve root compression [25, 26]. In addition, irritation or distention of the vertebral periosteum by a space-occupying lesion is a possible cause of axial back pain in patients with infections or tumors.

3.1 Discogenic Low Back Pain

The most common clinical manifestation of discogenic low back pain is persistent axial back pain, which may or may not be associated with radicular symptoms. Prolonged sitting, bending, lifting, and straining often precipitate discogenic low back pain. Pain relief may occur with rest or change in position.

Discogram and disc provocation with intradiscal injection of contrast will provoke characteristic pain and will allow for a radiographic visualization of the annular tear and disc protrusion. CT scan after discogram can reveal the site of annular tear and its severity [27, 28] (Fig. 11.23).

Although the majority of discogenic lower back pain can be successfully managed nonoperatively, surgical intervention may be utilized for the management of persistent pain in patients with identified pathology. Surgical treatment has been described for axial back pain in patients with degenerative changes secondary to internal disc derangement. Traditional treatment methods for disc derangement include spinal fusions with and without instrumentation. More recently, total disc arthroplasty has been added to the spine surgeon’s armamentarium. Percutaneous endoscopic selective discectomy and annuloplasty is another treatment option for discogenic low back pain, in which the impinged nucleus pulposus is taken out and the annular tear is denervated [29,30,31].

Posterolateral intradiscal decompression and thermal annuloplasty have been reported to treat discogenic low back pain, with which it is difficult to approach the dorsal aspect of the posterior annular fibrosus [29] (Fig. 11.24). More accurate techniques are needed to treat the intradiscal lesions and the dorsal aspect of the posterior annular fibrosus simultaneously. Far lateral approach can be easily applied to directly approach the annular tear at L4–5 level (Fig. 11.25) while transforaminal approach with foraminoplasty (Fig. 11.26) or interlaminar approach (Fig. 11.27) should be needed to target the annular tear at L5S1 level.

3.2 Zygapophysial Joint Pain

The zygapophysial joints are true synovial, diarthrodial joints that are richly innervated with sensory nerve fibers. The zygapophysial joints of the lumbar spine carry approximately 18% of the load placed on the lumbar spine. As with any joint, repetitive weight-bearing activities and microtrauma can lead to the development of joint degeneration and osteoarthritis. Patients with degenerative changes of the zygapophysial joints can experience axial back pain. Generally, the zygapophysial joint-related pain is worse with extension and rotation activities. Radiologic findings are often nonspecific and poorly correlate with symptoms [32,33,34]. Medial branch nerve blocks can be used to detect the presence of zygapophysial joint pain in patients with axial back pain [35, 36].

Denervation of lumbar zygapophysial joints is a procedure historically used for the treatment of back pain caused by disease of these joints. Percutaneous lumbar medial branch neurotomy has been indicated as the effective methods for the treatment of facetogenic chronic back pain. The theoretical basis of this neurotomy is denaturing the nerves innervating the painful joint and blocks the afferent pathway of the source of the chronic low back pain. The denervation is directed at the medial branches of two adjacent posterior rami of the spinal nerves because each joint receives innervation from both the nerve exiting that level and the superjacent nerve [36,37,38].

A previous study reported that the effective rate of percutaneous lumbar medial branch neurotomy is only 43–80%. Anatomical variations of the medial branch of dorsal ramus anatomy, incorrect placement of electrode, incomplete ablation, and nerve regeneration may be the important factors affecting the effectiveness of percutaneous neurotomy. In a study, Li et al. [39] found multiple anatomic variants of the medial branch anatomy. In clinical practice, percutaneous puncture technique may not achieve satisfactory therapeutic benefit if it fails to reach the location of the anatomic variants of the nerve. Relief after percutaneous lumbar medial branch neurotomy typically lasts between 6 and 12 months. Pain recurs when the nerves regenerate, but relief can be reinstated by repeated neurotomy. Successful treatment which repeated two and three times has been reported; however, no limit has yet been established as to the number of times that the procedure can be successfully repeated to maintain relief of pain [35, 36].

Dorsal endoscopic rhizotomy can contribute to the denaturing of the normal and varied medial branches of the nerve (Fig. 11.28). It can directly cut off the medial branches, which significantly reduces the possibility of the nerve regeneration and results in a low recurrence of pain [39, 40]. In a study, Li et al. [39] found that the excellent/good McNab outcomes of the 1-year postoperative evaluation were recorded as 97.8%, with a recurrence rate of only 2.2%, suggesting that dorsal endoscopic rhizotomy achieved good therapeutic results.

Currently, there has been no consensus on the number and levels of segments for dorsal endoscopic rhizotomy. Segment selection is usually speculated according to the location of the referred pain and local tenderness. Using a comparative double block control, Manchukonda et al. reported that blocking the L2–5 (namely L3–S1 zygapophysial joint) medial branch of the dorsal ramus of the spine nerve was the most effective modality in the diagnosis of the lumbar zygapophysial joint pain. In Li ZZ’ study [39], the low back pain mostly arises from the L3–S1 zygapophysial joints, which was consistent with the previous study.

3.3 Sacroiliac Joint Pain

The sacroiliac joint pathology may be a source of axial back pain since branches of the L4–L5 and S1–S2 dorsal rami innervate the sacroiliac joint (SIJ). The SIJs are diarthrodial, encapsulated joints. SIJ disorders often develop in the setting of inflammatory conditions, such as a spondylotic arthropathy, or in a posttraumatic setting. Patients with SIJ arthropathy typically complain of dull, aching pain, gluteal discomfort, especially with weight bearing and with ipsilateral hip and lumbosacral flexion and extension maneuvers. Plain X-rays can assess changes within the SIJs. In addition, diagnostic injections are essential for the diagnosis of SIJ-derived pain [41,42,43].

If a patient has a positive response to the SIJ injection after having failed nonoperative care, the next treatment option is often radiofrequency denervation or rhizotomy. The innervation of the SIJ varies among individuals, making it more difficult to be confident that the probe is in an appropriate position to effectively desensitize the targeted nerve. Particular attention should be paid to S1, S2, and S3 dorsal rami as in a recent cadaveric study they were found to contribute to the plexus of nerves innervating the SIJ in almost all specimens. Even with successful rhizotomy, the desensitized nerve may redevelop and the patient’s symptoms return. Results of a meta-analysis evaluating the effectiveness of SIJ radiofrequency ablation at 3- and 6-month follow-up found the treatment to be effective. This was based on the findings that based on a sample size weighted calculation, more than half of the patients experienced at least 50% pain relief at 3 and 6 months after the denervation [44, 45]. Dorsal endoscopic rhizotomy can contribute to the long-lasting denaturing of the normal and varied L5–S2 dorsal ramus [46] (Fig. 11.29).

4 Zygapophysial Joint Cyst

Synovial cysts are most commonly found in the lumbar spine, mostly at the L4–L5 level. They usually develop in patients with degenerative disc disease, zygapophysial arthropathy, and degenerative spinal stenosis. Quite frequently degenerative spondylolisthesis or zygapophysial joint instability is also found at the level of cyst formation. The latter findings, it is thought, support the notion that increased segmental motion plays a role in the pathogenesis of these cysts. Typically the cysts occupy the posterolateral aspect of the spinal canal (Fig. 11.30) or around the tip of superior articular process (Fig. 11.31), are adjacent to the facet joints, and are attached to the zygapophysial joint capsule. They contain serous or gelatinous fluid and measure up to 2 cm in diameter [47, 48].

MRI will show an extradural lesion with smooth surfaces adjacent to the facet joint. T1-weighted images may show the cyst as hypointense, isointense, or hyperintense when it contains blood. T2-weighted images show a hyperintense lesion that, at times, may communicate with the facet joint. In contrast enhanced studies the cyst’s walls may enhance and show its impact on the adjacent nerve roots.

Following the diagnosis of a zygapophysial joint cyst surgery should be considered if no relief is obtained after conservative treatment or when the symptoms recur. Percutaneous endoscopic total cyst excision can be performed in order to prevent cyst recurrence. Spinal stabilization should be performed in patients with local instability. Most patients do well postoperatively.

5 Osteoid Osteoma

Osteoid osteoma is a benign tumor found in young males in the second decade of life. Typically, the tumor is located in the posterior elements—the pedicles (Fig. 11.32), facet, or the laminae. Most of these tumors are found in the lumbar region and, less frequently, in the cervical region [49, 50].

Patients complain of unrelenting axial pain that is worse at night. The pain responds well to aspirin and NSAIDs . Antalgic scoliosis may be observed on physical examination.

Patients with unrelenting symptoms should be operated on. Percutaneous endoscopic total excision offers permanent cure [50, 51].

6 Burst Fractures

In lumbar burst fracture , the vertebral body is partially or completely comminuted and fragments of the posterior wall are retropulsed into the spinal canal, occasionally causing neural injuries. A minor vertical split through the posterior arch may also be found in these injuries; however, its contribution to instability is negligible because the posterior ligamentous complex is intact. Flexion and compression applied to these fractures may result in an additional loss of vertebral body height and spinal canal encroachment with risk of neurological damage.

Common radiological findings include widening and loss of vertebral body height, local kyphotic deformity, shortening of the posterior wall, and increase in the interpedicle distance. The distance between spinous processes should not (or only minimally) increase, even in kyphotic injuries. Displaced fragments into the spinal canal are better visualized on CT or MRI.

Patients with incomplete neurological injuries after a burst fracture who have residual spinal cord compression may benefit from acute surgical decompression and stabilization. Patients who suffer a complete neurological injury after burst fractures do not require immediate surgical decompression, regardless of the presence of spinal cord compression [52, 53].

The surgical goals of treating burst fractures are to decompress the spinal canal, if needed, and to restore spinal alignment. Neural structures can be decompressed either through indirect reduction, posterior or anterior approach. Sometimes retropulsed fragments can be reduced indirectly by the application of distractive forces (ligamentotaxis) and realignment of the kyphotic curvature. This procedure is successful as long as the posterior longitudinal ligament is intact during the application of distractive forces across the affected segment. When the posterior longitudinal ligament is injured or in the subacute setting, particularly when soft tissue healing prevents adequate reduction and realignment, percutaneous endoscopic direct decompression is possible through a transforaminal approach by performing a foraminotomy and partial resection of pedicle (Fig. 11.33). Percutaneous pedicle screw system can be applied to restore spinal alignment and stability [54,55,56].

7 Lumbar Segmental Instability

Lumbar segmental instability represents the inability of the spinal motion segment to bear physiologic loads resulting in abnormal motion between two lumbar vertebrae. The most common complaint is back pain, usually mechanical in nature, although leg pain or neurologic findings from dynamic stenosis may also be seen [57,58,59]. The diagnosis may be made on the basis of abnormal motion on flexion/extension radiographs. Lateral flexion/extension radiographs demonstrating sagittal plane translation of greater than 12% of the AP diameter of the vertebral body or relative sagittal plane angulation of greater than 11° are the commonly accepted definition of instability [60]. Spinal fusion is often needed. Percutaneous endoscopic decompression combined with insertion of expandable cages through transforaminal or interlaminar approach can be applied to treat lumbar segmental instability [61, 62] (Fig. 11.34).

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The Department of Orthopedics Surgery, The Fourth Medical Center of Chinese PLA’s General Hospital, Beijing, China
Zhen-Zhou Li

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Zhen-Zhou Li
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Department of Neurosurgery, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seocho gu, Seoul, Korea (Republic of)
Jin-Sung Kim
Department of Neurosurgery, Kyung Hee University Medical Center, Seoul, Korea (Republic of)
Jun Ho Lee
Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea (Republic of)
Yong Ahn

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Li, ZZ. (2020). Indications. In: Kim, JS., Lee, J., Ahn, Y. (eds) Endoscopic Procedures on the Spine. Springer, Singapore. https://doi.org/10.1007/978-981-10-3905-8_11

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DOI: https://doi.org/10.1007/978-981-10-3905-8_11
Published: 04 September 2019
Publisher Name: Springer, Singapore
Print ISBN: 978-981-10-3904-1
Online ISBN: 978-981-10-3905-8
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