Abstract
Context/objective: At present, there is no consensus on the most effective surgical method for treating symptomatic lumbar spinal stenosis (LSS). Total laminectomy, which is frequently used at this time, destroys the posterior midline structure, causing many postoperative complications. We have designed a new surgical approach instead of total laminectomy. In this paper, we aimed to describe the surgical method of endoscopic modified total laminectomy for lumbar spinal stenosis as well as to explore its early efficacy.
Participants: Patients with symptomatic LSS who underwent endoscopic modified total laminoplasty between August 2016 and August 2017 were eligible for our study.
Outcome measures: Before surgery and one year after surgery, we measured lower limb pain and back pain by visual analog scale (VAS), disability via Oswestry Disability Index (ODI), and severity of back pain according to the Japanese Orthopedic Association Score for Back Pain (JOA), while any complications were also assessed.
Results: Endoscopic modified total laminoplasty was performed on 22 LSS patients, including eight males and 14 females(mean age = 59.3 ± 9.6 years). We found statistically significant differences before and one year after surgery for VAS lower limb pain and back pain, ODI and JOA scores(P < 0.001). Complications included intraoperative dural tears(n = 1),and weak fusion between the lamina and the vertebral body (n = 1).
Conclusion: Endoscopic modified total laminectomy is a promising surgical approach which reduces patient suffering and improves patient quality of life.
Keywords: Total laminectomy, Laminoplasty, Minimally invasive, Endoscope
Introduction
LSS is a syndrome which consists of a series of symptoms caused by degenerative changes to the lumbar intervertebral disc, synovial degeneration, hypertrophy of the ligamentum flavum, hyperplasia of facet joints, and other pathological changes. It may also be caused by congenital bony stenosis, although secondary stenosis is more common.1 As lifestyles change, incidences of LSS increase year by year,1,2 while 21% of those over 60 have LSS only by radiological criteria.3 The typical clinical manifestation is neurogenic claudication, while others include static back pain, radicular lower extremity pain, or a variable combination of these symptoms.1,3 LSS can be treated surgically or non-surgically. Non-surgical treatments, such as medication, physical therapy and epidural injections have been reported to reduce the suffering of some patients.1 However, surgery is the best choice for patients who do not respond to non-surgical treatments. Spinal canal decompression is the most common surgical treatment for LSS.1-5
There are many current surgical methods for treating LSS, most of which have good clinical outcomes.8 Traditional laminectomy is the most standard of these procedures.9 However, traditional laminectomy can extensively disrupt the posterior midline structure(through spinous processes, vertebral arches, interspinous and supraspinous ligaments), and may contribute to high rates of postoperative lumbar instability, postoperative pain, and perioperative complications.10,11 An increasing number of surgical methods have been proposed to address this problem and to preserve, as far as possible, the structure of the posterior midline structure. These methods include sublaminar-trimming laminoplasty, fenestration with undercutting decompression, bilateral microdecompression laminatomy,1,3 and so on.9,26 Indeed,compared with traditional surgery, these techniques could alleviate patients’ suffering and improve their quality of life. However, these techniques are technically demanding due to the limit of surgical field of view and may result in a higher rates of complications9,12 and insufficient decompression.13 Therefore, explorations into the treatment of LSS continue to be of value.
The application of endoscopic techniques in recent years is good news for patients.6,7 We designed an endoscopic modified total laminectomy for LSS combined with minimally invasive concepts. In this study, we aimed to describe the surgical approach of endoscopic modified total laminectomy for LSS and explore its early efficacy.
Materials and methods
Patients
Since August 2016, we have been using endoscopic modified total laminectomy as an alternative to standard laminectomy for the treatment of LSS in our department. In this study, we retrospectively analyzed patients who had single- or multi-segmental symptomatic LSS, with or without degenerative spondylolisthesis, who underwent endoscopic modified total laminectomy between August 2016 and August 2017.
In this study, we included symptomatic patients whose lumbar spinal X-ray before surgery showed that the spine canal antero-posterior diameter was less than 10 mm, and/or lumbar CT before surgery showed that spine canal cross-sectional area was less than 75 mm2 who had all been treated conservatively for at least three months. Given the limitations of this surgical method and the fact that certain patients could not satisfactorily complete the assessment tasks, patients were excluded from the study if they had simple intervertebral foramen stenosis, tumor, mental illness, severe organic disease, or a history of previous lumbar spinal surgery. All patients were involved in preoperative education before surgery and were informed that they had the right to stop follow-up at any time. This study was approved by the scientific research and clinical trial ethics committee.
Surgical approach
Selective fusion and spinal decompression were used for patients with LSS and degenerative spondylolisthesis.8 All surgeries are performed by the same experienced surgeon.
We will use the L4-L5 stenosis with L4-L5 vertebral instability as an example here. Following general anesthesia, the patient was positioned on the console, then disinfected and put on the sterile towel. The fourth lumbar spinous process was marked at the intersection of the line connecting the highest point of bilateral iliac spine and the posterior median line. Once the operation area was accurately positioned by C-arm, a posterior median incision of approximately 2.5 cm was made along the marked line. Fat fascia was separated layer by layer, while the left paraspinal muscle was separated along the left side of the multifidus muscle after sawing the spinous process. A self-made hooked half-channel (Fig. 1B/①) was used to expose the left laminar and facet joints and then protect the joint capsule. The L4 spinous process was transversely truncated with a pendulum saw, after which the free end spinous process, the accessory muscle and the ligament of the spinous process were retained and pulled to the right. This revealed the right lamina and facet joints and protected the right joint capsule. We then accessed the endoscope system (Fig. 1A, B/③④ and C, Patent No: 201820246752X), and inserted the pedicle screws after finding the bilateral pedicle insertion points of L4 and L5 with the aid of C-arm (Fig. 2B and C). The self-made belt loop half-channel (Fig. 1B/②) was used to construct the operation channel. The osteotome and coronal plane of the lamina were inclined at an angle of 45°, the sagittal plane of the lamina was inclined at an angle of 30°, and the entire lamina was carefully removed. The facet joints were then retained. After excision of part of the interspinous ligament – which does not affect the stability of the spine13 – the L4 proximal spinous process was raised with a handkerchief forcep and combined with the periosteum elevator to completely peel off the full lamina. An endoscope was used to protect the dura mater and nerve roots as well as to completely decompress the nerve root canal, lateral crypt, clear adhesion tissue, and hyperplastic bone. The degenerative nucleus pulposus between L4 and L5 was removed and the adjacent cartilage endplates were treated, after which moderate autologous bone and an appropriate cage type were inserted. C-arm fluoroscopy was used to confirm that the cage was in a good position, after which the L4 lamina was trimmed (removing the ligamentum flavum to help protect the spinal cord and nerve roots from damage) and the micro-small plate used to implant the lamina(Fig. 1D) back into place. (Since the osteotome and sagittal plane were at an angle of 30° when the lamina is removed, restenosis caused by laminar collapse was avoided)A bar was then placed on each side to reduce vertebral instability (Fig. 2B and C). Hypertrophic joints were then treated and then the free spinous process was stitched into the original position, and sutured layer by layer after flushing the surgical area.
Figure 1.
(A) endoscope source (B) ① hooked half-channel ② Belt loop half-channel ③ Skin protectorscan ④ Aspirator, which can be combined with the endoscope source (C) Intraoperative operation display (D) Free lamina with the micro-small plate.
Figure 2.
(A) Single-segment incision length (B) and (C) Lumbar X-Ray for three days after surgery.
Clinical evaluation
We collected the following data: (1) Back pain and lower limb pain VAS scale, functional disability ODI questionnaire, and patient health status JOA questionnaire both (within one week before surgery, or during outpatient consultation before surgery)and one year after surgery; (2) Blood loss and surgical duration(obtained from anesthesia record); (3) Incision length, postoperative hospital stay and time bedbound(obtained from patients’ case history); (4) X-rays the third day and one year after surgery to assess lumbar stability and cage displacement. Magnetic Resonance Imaging (MRI) was used one year after surgery to assess postoperative dural scar formation and adhesion. The standard for complete fusion of the replanted lamina was the formation of continuous osteophytes between the replanted lamina and vertebral body. Solid intervertebral trabeculation with no segmental motion in the dynamic view of the lumbar spine was the standard of complete interbody fusion.
The Visual analog scale (VAS) is marked from 0 to 10 and has 4 levels: 0 (no pain), 1–3 (mild pain), 4–6 (moderate pain), 7–10 (severe pain). Back and lower limb pain are assessed by asking patients for a subjective measure of their sensations. This is considered a strong, clinically useful, reliable and valid measure of pain intensity.14 Minimum clinically important difference (MCID) for back pain and lower limb pain VAS is a net improvement of 2.5 points.15
The Oswestry Disability Index (ODI) is a 10-item questionnaire which is used to assess extent of pain, ability to perform daily activities, ability to lift, walking, sitting, standing, sleep quality, effect of pain on sexual activity, effect of pain on social activity, and ability to travel.16 Patients’ extent of disability was determined by answering these 10 questions. The measure is considered to have good psychometric properties.17 Each question scores from 0 to 5, with the result being the percentage of the actual score to the highest score; a higher ratio means greater disability. Minimum clinically important difference for ODI is a net improvement of 18.8 points.15
The Japanese Orthopedic Association Score for Back Pain (JOA) is a 16-item questionnaire that is used to respectively assess severity of back pain, lower limb pain, tolerable walking distance, laségue sign, sensory disturbance, dyskinesia, bladder control, and difficulty performing the activities of daily living.18 It has satisfactory psychometric properties,19 and patients’ severity of back pain was determined through these 16 questions. The maximum total score is 29, with lower scores meaning greater disability.
Statistical analysis
Continuous and ordinal variables before surgery and one year after were compared using the Wilcoxon-signed rank test. Sex, age, weight, hospital stay, and antero-posterior diameter are expressed as mean ± standard deviation. The operative duration, intraoperative blood loss and incision length are expressed as lowest to highest mean values. Results were analyzed using SPSS18.0 statistical software and P ≤ 0.05 was considered statistically significant.
Results
A total of 25 LSS patients received endoscopic modified total laminoplasty between August 2016 and August 2017. Of these, three were excluded due to loss of follow up one year after surgery (n = 2) or mental illness (n = 1). The other 22 cases were followed up for one to two years, mean 18.3 months. Ten were lost to follow-up (n = 9) or died (n = 1) two years after surgery.
Patients’ basic information and clinical characteristics are shown in Table 1. Participant’s age ranged from 42 to 72, and most were women (63.6%).
Table 1. Basic information and clinical characteristics of patients before surgery.
| Variable | N = 22 |
|---|---|
| Sex, n (%) | |
| Male | 8(36.4%) |
| Female | 14(63.6%) |
| Age (years) | 59.3 ± 9.6 |
| Weight (kg) | 54.6 ± 8.8 |
| Decompression segment, n (%) | |
| 1 | 6(27.3%) |
| 2 | 13(59.1%) |
| 3 | 3(13.6%) |
| Fusion plus internal fixed segment, n (%) | |
| 1 | 7(31.8%) |
| 2 | 1(4.6%) |
| antero-posterior diameter(mm) | 6.45 ± 1.70 |
*Data are presented as mean ± standard deviation, unless otherwise indicated.
Operative duration, intraoperative blood loss and incision length are described in Table 2. Due to surgical characteristics, the operative duration, intraoperative blood loss and incision length (Fig. 2A) are expressed in terms of different numbers of segments.
Table 2. Operative duration,intraoperative blood loss and incision length.
| Variable | Operative duration (min) | intraoperative blood loss (ml) | Incision length (cm) |
|---|---|---|---|
| Single-segment (n = 6) | 130–180(147) | 50–300(135) | 2.2–2.7(2.5) |
| Double-segment (n = 13) | 140–250(159) | 80–1000(200) | 3.2–3.9(3.6) |
| Three-segment(n = 3) | 200–240(225) | 200–800(533) | 4.5–.9(4.7) |
*Data are presented as lowest value to highest value(mean), unless otherwise indicated.
Leg and back VAS, ODI, and JOA scores are described in Fig. 3. For each group of evaluation methods, there were significant improvements from before surgery to one year after (P <0.001). The proportion of patients with a net improvement in lower limb pain VAS, back pain VAS, and ODI scores one year after surgery which reached minimal clinically important difference accounted for 95.5% (n = 21), 86.4% (n = 19), and 90.9% (n = 20) of all patients, respectively.
Figure 3.
VAS leg and back pain, ODI, and JOA Back Pain scores before and one year after surgery (N = 22). ***P＜0.001. *Statistically significant differences between before and after surgery measurements as determined by the Wilcoxon-signed rank test.
Patients were bedbound after surgery for a range of one to two days. Hospital stays after surgery ranged from six to 13 days, with a mean of 8.4 ± 1.8 days.
One patient underwent intraoperative dural tears, surgical sutures were given during surgery, and no cerebrospinal fluid leakage occurred after surgery. Use of X-Ray at one year after surgery showed that one patient had a weak fusion between the lamina and the vertebral body. No other complications, such as restenosis or postoperative vertebral spondylolisthesis, were observed on X-Ray and MRI during the one year of follow-up.
Discussion
The typical lumbar canal diameter is defined as greater than 12 mm. Between 10 and 12 mm is relatively narrow, and less than 10 mm is extremely narrow.20 While the anteroposterior diameter and cross-sectional area of the spinal canal are not definitively related to a patient's symptoms,21 it is necessary to perform spinal canal decompression in patients with spinal stenosis, which is also an important point in the treatment of LSS. The most standard surgical procedure for decompression of the spinal canal is laminectomy. However, this process ignores the importance of protecting the posterior midline structure. CHO and colleagues believe that reducing muscle trauma can both reduce paravertebral muscle atrophy and increase spinal stability.13 Hu et al. described a group of rabbit experiments and concluded that the separation of the multifidus muscles adjacent to the spinous processes is a key cause of muscle atrophy.22 Alexis and colleagues conducted a study about patients with LSS with or without pedicle fixation, and stated that the extensive posterior approach with total laminectomy results in more severe muscle atrophy.23 Kakiuchi et al. state that the key to long-term efficacy in spinal decompression in two or more segments is the integrity of the spinous processes.24 Ligament rupture can increase stress on facet joints, intervertebral discs and other ligaments. The integrity of the preserved ligament complex can be used as a tension band when the spine is bent, thus stabilizing the decompressed spine.25 Therefore, whether with paravertebral muscles, ligaments or bony structures, this integrity has an impact on the prognosis of patients with LSS.
The current pursuit of retaining the posterior midline structure has become the common goal of spinal surgeons. CHO et al. detailed a modified surgery involving a split–spinous process laminotomy and discectomy which can reduce paravertebral muscle damage, lower back pain, shorten bedboud time and hospital stay, and can maintain the stability of the spine when compared with conventional surgery.13 Liu and colleagues explored a procedure known as sublaminar-trimming laminoplasty. In that study, 49 patients with LSS were treated with neurological symptoms and their functions were followed up for three years. No case of restenosis appeared.26 However, this method inevitably has the same disadvantage as other minimally invasive surgery in that the operation channel is narrow.9,12,25 Kwon et al. described two major advantages of a procedure called central decompression laminectomy: retaining almost all facet joints and joint capsules as well as providing a wide operating field of view. They found that patients who underwent central decompression laminectomy achieved short-term symptom recovery, but long-term efficacy was not reported.9
In recent years, given the development of both surgical approaches and endoscopic instruments, endoscopic techniques have been widely used. Lee et al. reported on four patients who were successfully treated for all lesions through a single endoscopic approach of percutaneous endoscopy. These authors also revealed the shortcomings of percutaneous endoscopic techniques, which cannot be applied to all forms of LSS, especially for those with severe LSS with spondylolisthesis or instability.6 To extend the advantages of endoscopy, we applied it to total laminectomy. According to Fig. 3, VAS back pain and leg pain, ODI and JOA scores at one year after surgery were significantly improved compared with preoperative scores(P < 0.001). The net improvement in lower limb pain VAS, back pain VAS, and ODI scores for most patients reached MCID, suggesting that most patients who underwent this modified procedure experienced meaningful relief. Indeed, this surgery can improve a patient's prognosis and quality of life. The fusion rate of the lamina is 95.5%, which may relate to the loosening of the fixed micro-steel plate during operation. Based on our experience, it is more secure to fix the vertebral plate at a 45° angle with the ‘T’ shaped micro-small plate.
The advantages of this surgery are as follows. Firstly, one side of the paravertebral muscle and part of the spinous process ligament complex are preserved. Reducing the posterior structure damage, in theory, can reduce the occurrence of paravertebral muscle atrophy and blood loss as well as maintaining the stability of the spine. Secondly, replacement of laminectomy with laminoplasty has reconstructed the spinal canal to prevent scar formation and adhesion on the dura mater and to maintain the stability of the spine to some extent. Thirdly, our self-developed technology, which combines the endoscope source with the aspirator, helps to create a clear field of view and facilitates the search for bleeding points and hemostasis, further reducing the amount of bleeding. It can help protect the spinal cord and nerve roots while completely decompressing the spinal canal, lateral recessed canal, nerve root canal and treatment of hypertrophic joints, as well as improving the safety of the operation. Fourthly, the half-channel technology can help to create a ‘conical’ surgical channel and, at the same time, the position of the moving half-channel can be flexibly changed, meaning spinal canal decompression can be performed with a smaller surgical approach. This not only reduces residual dead space, but also maximizes the surgical field of vision. According to our study, the mean length of the incision in single-segment decompression (n = 6) is 2.5 cm, the mean length of the incision in double-segment decompression (n = 13) is 3.6 cm, and the mean length of the incision of in three-segment decompression (n = 3) is 4.7 cm. This small incision caters satisfies patients. Additionally, our self-developed skin protectors can helps reduce skin damage caused by smaller operation inlets and reduces the chance of poor wound healing or infection.
Limitations of the endoscopic modified total laminectomy are as follows. Firstly, despite the help of endoscopy and hemichannels, decompression therapy in narrow operating channels can be difficult for many surgeons, especially those with less experience. We believe that the technical difficulty of this surgical approach is the complete dissection of the whole laminar (susceptible to dura and nerve roots). Therefore, it is necessary to formally train before surgery. Secondly, the pursuit of minimally invasive surgery also prolongs the operation time, but as surgeons become more experienced in the technique, our operation time is gradually shortening.
In this study, we selected LSS with or without vertebral instability and performed selective decompression, fusion, and internal fixation. However, fusion surgery may increase costs, blood loss, and length of hospital stay, which may affect the outcome of this study.27,28 Therefore, in the future, we plan to take a simple case of LSS, and carry out a study using a control group.
Conclusion
Based on this study, we suggest that endoscopic modified total laminectomy can alleviate pain and improve both quality of life and patient satisfaction. Compared with traditional total laminectomy, this procedure retains as much of the posterior midline structure as possible, theoretically reducing lumbar instability, postoperative bleeding and complications. However, data bias may result due to the small sample size in this study. Therefore, a broader, longer-term follow-up study is needed to confirm the safety and stability of this modified procedure.
Disclaimer statements
Contributors None.
Funding None.
Conflicts of interest Authors have no conflict of interests
to declare.
Ethical approval
This study was approved by the local scientific research and clinical trial ethics committee (S-2019-LW-044).
Acknowledgements
The authors wish to thank professor Penghui Yan and professor Nan Zhou for their support of this study. The authors thank Zhengxi Li and Wang Niufor proofreading of the draft.
References
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