Percutaneous Endoscopic Lumbar Foraminoplasty for Resection of Synovial Cyst

Synovial cyst is an extradural mass that compresses nerve root or thecal sac. Surgical excision with partial hemilaminectomy and medial facetectomy is commonly used for synovial cyst. Remarkable advancements in endoscopic spinal surgery have led to successful outcomes comparable to conventional open surgery. Here we introduce percutaneous endoscopic lumbar foraminoplasty for resecting synovial cyst as a minimal invasive technique. A 59-year-old woman presented with radicular pain at left L5 dermatome. Magnetic resonance images demonstrated a synovial cyst at left L4-5 facet joint and degenerative spondylolisthesis on L4-5. Under endoscopy, synovial cyst was removed by piecemeal method after transforaminal endoscopic foraminoplasty that removed part of superior facet. Her symptoms were relieved and the patient was discharged the next day. Therefore, percutaneous endoscopic lumbar foraminoplasty can be used as a minimally invasive surgical option for synovial cyst. It may provide less traumatization and affect less postoperative instability

Comparative Analysis With Modified Inclined Technique for Posterior Endoscopic Cervical Foraminotomy in Treating Cervical Osseous Foraminal Stenosis: Radiological and Midterm Clinical Outcomes

Objective We compared the midterm clinical and radiological outcomes between 2 types of full endoscopic posterior cervical foraminotomy, including conventional posterior endoscopic cervical foraminotomy (PECF) and modified inclined technique for PECF. Methods One of the 2 types of PECF surgery was performed for defined cervical foraminal stenosis. The foraminal expansion ratio and facet resection rate and foraminal stenosis grade were measured using magnetic resonance imaging. Visual analogue scale (VAS) scores for neck and arm pain, neck disability index, MacNab criteria, operation time, hospital stay, and complications, including postoperative dysesthesia, were assessed. Clinical and radiological parameters were compared between the 2 surgical groups. Results There were 49 and 46 patients in the PECF and modified-PECF groups, respectively. The modified-PECF group showed significantly higher expansion of distal foraminal diameter and foraminal height, and a lower facet resection rate compared to PECF group (in all, p<0.001). The modified-PECF group displayed significantly lower VAS score for neck pain at 1 day and 1 week after surgery and lower arm pain VAS score after 6-month follow-up (p=0.002, p=0.001, p=0.002, respectively). Conclusion Compared with the PECF, the modified inclined technique has radiologic benefits, including enhanced facet joint preservation, restoration of the natural course of nerve roots, and prevention of restenosis by expanding the superior articular process base, especially in grade 2 foraminal stenosis. Furthermore, the modified inclined technique significantly improved the postoperative VAS score for neck pain within the 1-week follow-up and that of arm pain after 6-month follow-up

Current Status of Biportal Endoscopic Decompression for Lumbar Central Stenosis

Degenerative lumbar spinal stenosis commonly occurs in elderly patients aged above 50-60 years. Surgical intervention is indicated for patient refractory to conservative management, and microscopic decompression has been used for direct spinal canal decompression. The development of surgical instruments and spinal endoscopic system can make possible endoscopic surgery as the useful treatment option for degenerative lumbar disease. Endoscopic spine surgery was mainly preformed in lumbar disc disease through transforaminal route. And then, endoscopic interlaminar approach was introduced using endoscopic drill, more developed endoscopic disc forceps, and Kerrison punches, and so on. Uniportal endoscopic spine surgery through interlaminar space can make possible direct spinal canal decompression in cases with lumbar spinal stenosis, however stiff learning curve still remains the limitation of this surgery. Biportal endoscopic spine surgery was also introduced as the minimal invasive spine surgery, which is basically similar to microscopic surgery and relatively familiar approach to spine surgeons. Biportal endoscopic spine surgery can offer clean operative view in monitor through continuous irrigation and endoscope with large diameter compared to uniportal endoscopic equipment, and this approach may be alternative surgical approach for decompression of lumbar spinal stenosis. Now many spine surgeons perform biportal endoscopic surgery for lumbar central spinal stenosis, and the reports have been published. He we write the technical procedure of biportal endoscopic surgery for lumbar spinal stenosis, discussing about surgical considerations, and also review the surgical outcomes from the previously published articles

Full Endoscopic Interlaminar Contralateral Lumbar Foraminotomy for Recurrent L5-S1 Foraminal-extraforaminal Stenosis: A Case Report with a Technical Note

After endoscopic lumbar foraminotomy, decreased disc height commonly causes foraminal restenosis and accompanying lateral recess stenosis. Interlaminar contralateral endoscopic lumbar foraminotomy can be used to treat multiple recurrent lesions instead of fusion surgery. Dorsal foraminal-extraforaminal decompression is challenging because of severe perineural adhesions. Therefore, neural decompression should be focused on the ventral foraminal expansion along the virgin dissection plane between the exiting nerve root and ventral foraminal pathologies. The prominent bony spur and herniated disc were removed using an endoscopic drill and forceps. As the foramen was enlarged, the endoscope was introduced deeper through the caudal-ventral foramen space to explore the extraforaminal and far-out lesions. Postoperatively, neurological deficits of L5 radiculopathy and radiating leg pain improved. The expanded foraminal-extraforaminal space was well maintained without progression of lateral wedging on the one-year follow-up images. We successfully treated recurrent foraminal-extraforaminal stenosis and combined lateral recess stenosis using the full endoscopic interlaminar contralateral approach at the L5-S1 level. This technique may be an alternative surgical method to treat the recurrent foraminal-extraforaminal stenosis in the collapse of the L5-S1 neuroforamen. However, this technique should be considered in highly selected patients unsuitable for fusion operations

Usefulness of Oblique Lumbar Magnetic Resonance Imaging for Nerve Root Anomalies and Extraforaminal Entrapment Lesions

Study Design A retrospective review of prospectively evaluated magnetic resonance (MR) images. Purpose Routine lumbar axial and sagittal MR images may not clearly demonstrate nerve root anomalies and entrapments in the extraforaminal region. Thus, lumbar extraforaminal lesions or nerve root anomalies may be underdiagnosed because of unfamiliar radiological anatomy. We aimed to investigate the clinical efficacy of our oblique magnetic resonance imaging (MRI) technique for diagnosing nerve root anomalies and entrapment lesions. Overview of Literature Evaluation of clinical usefulness of oblique lumbar MRI for nerve root anomalies and extraforaminal entrapment lesions. Methods In total, 162 patients (60 males and 102 females; mean age, 59.8±17.8 years) with suspected nerve root anomalies and entrapments in routine axial and sagittal MR images underwent unilateral or bilateral oblique lumbar T2-weighted MRI. The axial angle of the oblique image was parallel to the foramen. The oblique MRI findings of the symptomatic side were compared with those of the asymptomatic side in cases with unilateral pathologic lesions. Interobserver agreement was analyzed using kappa statistics. Results The following abnormal findings were obtained: nerve root entrapment due to foraminal stenosis in 82 cases; extraforaminal disk herniation in 29; conjoined nerve root in six; and foraminal bony cyst in one. Forty-three of the 46 patients experienced unilateral lateralizing symptoms, unilateral nerve root entrapment due to foraminal stenosis, herniated disk, and extraforaminal bony cyst compared with the asymptomatic contralateral side (p <0.05). Conclusions Our results suggest that oblique lumbar MRI is a simple and valuable modality for diagnosing anomalous lumbar nerve root lesions and entrapment

Inter- and Intra-observer Reliability of MRI for Lumbar Lateral Disc Herniation

Background: The authors analyzed inter- and intra-observer agreement with respect to interpretation of simple magnetic resonance T1- and T2-weighted axial and sagittal images for the diagnosis of lumbar lateral disc herniation, including foraminal and extraforaminal disc herniations.Methods: Forty-two patients in whom lumbar lateral disc herniation was suspected or confirmed by simple magnetic resonance imaging at one institute between May 2003 and December 2004 were included. The magnetic resonance images consisting of T1- and T2-weighted axial and sagittal images, and these were reviewed blindly and independently by three orthopaedic spine surgeons in a random manner. The images were interpreted as positive or negative for lateral disc herniation on 2 different occasions 3 months apart. Results were analyzed using Cohens kappa statistic, and strengths of agreements were determined using the Landis and Koch criteria.Results: The kappa values for inter-observer agreement averaged 0.234 (0.282, 0.111, and 0.308 respectively) on the first occasion, and 0.166 (0.249, 0.111, and 0.137 respectively) on the second occasion, with an overall mean value of 0.200. Thus, the strength of agreement was only slight-to-fair according to the Landis and Koch criteria. Kappa values for intra-observer agreement averaged 0.479 (0.488, 0.491, and 0.459 respectively), indicating moderate agreement.Conclusions: The present study indicates that simple magnetic resonance imaging is not a reliable imaging modality for diagnosing lumbar lateral disc herniation. Another imaging study with improved diagnostic values should be developed to diagnose this pathologic finding.Keywords: Lumbar lateral disc herniation, Inter-observer reliability, Intra-observer reliability, Magnetic resonance imagingOAIID:oai:osos.snu.ac.kr:snu2009-01/102/0000004226/1SEQ:1PERF_CD:SNU2009-01EVAL_ITEM_CD:102USER_ID:0000004226EMP_ID:A076317DEPT_CD:801FILENAME:E019T_CiOS-2009_Kim_Inter-and Intra-observer Reliability of MRI for Lumbar.pdfDEPT_NM:의학과EMAIL:[email protected]_YN:NCONFIRM:YCONFIRM: