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Lumbar Spinal Stenosis Treated Using Minimally Invasive Microsurgical Techniques

Microendoscopic Laminectomy for Spinal Stenosis

Peer Reviewed

If non-surgical measures do not offer adequate relief for your spinal stenosis, the doctor may recommend back surgery.  This article first reviews general surgical options for lumbar spinal stenosis, and then, it covers a minimally invasive spine surgery option:  microendoscopic laminectomy.

Surgical Options for Lumbar Spinal Stenosis

Who Is a Candidate for Surgery to Relieve Lumbar Spinal Stenosis?

Patients who are generally in good health should have no problem undergoing surgery. Age alone is not a major limiting factor however, if you have other medical conditions such as high blood pressure, or diabetes that typically accompany old age, surgery may pose greater risk.

Surgical Procedures: Laminectomy, Laminotomy, and Foraminotomy

The operations typically used to treat lumbar stenosis include the classic laminectomy, laminotomy, and foraminotomy.  For patients who meet the proper indications, these procedures can also be combined with a spinal fusion operation.

The most commonly used decompressive surgery is the laminectomy. To perform a classic laminectomy, a 3-4 inch incision is made in your lower back, though it may be longer depending on how many levels of your lamina are affected.

lumbosacral spine, posterior black and white drawing
 

A laminectomy involves removing the bony extensions (lamina) from the backside of the vertebral body which are causing pressure on the spinal sac and/or the nerve roots (see below).

surgical removal of spinous process
 

Laminectomy
 

Laminectomy Considerations
 

Often, only a portion of the lamina needs to be removed to relieve the pressure on the nerve roots (that is a laminotomy). The ligaments (ligamentum flavum) and soft-tissue (facet capsules, herniated or bulging discs) in the affected area are also removed to increase the canal space.

At the same time, a portion of the facet joints at the sides of the lamina may also be removed since they also cause increased pressure on the central and foraminal areas.

Stenosis causes pressure on central and foraminal areas
 

The goal of a foraminotomy is to enlarge the space where the nerve roots exit the spinal canal thus decreasing pressure on them. Foraminotomies can be done by themselves or often in conjunction with a laminectomy.

Addressing Spinal Instability:  Spinal Fusion

Some patients may develop instability of the spine with surgery. This occurs when a lot of bone needs to be removed and/or when multiple levels are operated on in order to provide adequate decompression. As such, many surgeons prefer more limited lamina removal (laminotomy) and only partial facet removal (medial facetectomy).

Others may already have instability from their disease, as in cases of spondylolisthesis. For all these patients, a spinal fusion is needed in addition to decompression. Spinal fusion involves grafting bone onto the spine and using instrumentation, such as screws and rods, to support the spine and provide stability. Your neurosurgeon can usually determine whether you will need a fusion prior to surgery so that you will be able to discuss this possibility beforehand.

Microendoscopic Laminectomy:  How It Works

The Microendoscopic laminectomy (MEL) is an exciting new treatment option for patients who are candidates for the surgical treatment of lumbar spinal stenosis. MEL accomplishes the same goal as the classical laminectomy but it involves using a minimally invasive approach, a state-of-the-art surgical endoscope for visualization , and microsurgical decompressive techniques.

A thin needle is placed under fluoroscopic (x-ray) guidance down to the involved level on one side of the midline spine (Figure 6a).

laminectomy, msd
 

A small ½ to 1-inch incision is then made around this needle. Using a set of tapered metal dilators passed over the guiding needle, the tissue and muscles are then gently spread off the underlying bone.

minimally invasive, msd
 

minimally invasive, discectomy
 

A hollow metal cylinder is then passed down to the area of the stenosis and secured. Through this working channel, a rigid surgical microendoscopic camera is placed to provide your surgeons with a close-up, magnified view of the pathology (see below).

lumbar spinal stenosis canulas surgical tools figure 6c fessler
 

lumbar spinal stenosis surgical tools figure 6d fessler
 

With this close-up operative view, your surgeon can then microsurgically remove the bone compressing the nerve roots thereby relieving the stenosis.

In addition, soft tissue such as the ligamentum flavum and herniated discs can also be removed through the MEL technique. In our experience, excellent decompression of both sides of the spinal canal can be achieved through this one-sided approach.

med, discectomy
 

med, disectomy
 

In the hands of experienced spinal surgeons, the same amount of decompression can be achieved through the MEL technique as would typically be obtained through open surgery.

Through the same incision, the surgeon can swing the endoscope to decompress the spinal level immediately above and below as well. Overall when compared to traditional open procedures, the MEL technique offers the attractive benefits of far less disruption of normal tissue, faster surgical time, decreased post-operative discomfort, quicker recovery time, and a typically more rapid return to normal activity. You should contact your surgeon to find out if the MEL operation is available in your area and whether you are a candidate for the procedure.

Recovery after Minimally Invasive Spine Surgery for Spinal Stenosis

During microendoscopic laminectomy (MEL) surgery to treat lumbar spinal stenosis, you will be asleep under general anesthesia. After surgery you will be taken to the recovery area where you will be monitored until you awaken. Most patients can begin getting out of bed on the same day surgery is performed. Activity is gradually increased and patients are typically able to go home within 2 to 5 days after a classic laminectomy and 1 to 2 days after MEL. However, these time frames may be longer depending on the extent your surgery.

Typically you will experience pain for a few weeks after surgery and you may need over-the-counter or prescription pain medications. Your spine surgeon may also prescribe a course of physical therapy to help you regain strength in your abdomen and back and promote a better recovery.

The total recovery time after lumbar spine surgery can take anywhere from 8 weeks to 6 months, depending on the severity of your condition before surgery as well as your overall health condition prior to surgery. Common sense tells you the healthier you are, the quicker you will heal.

Understanding the Risks in Spine Surgery

Decompressive laminectomy is the most common and successful surgery done for treatment of symptoms associated with lumbar spinal stenosis. However, it is still surgery and any surgery involves risk.

Your spine surgeon will discuss these risks in detail with you, but the most common ones are bleeding, infection, injury to the nerve, scarring, and the usual risks of anesthesia. Those with accompanying chronic health conditions such as diabetes, obesity, and high blood pressure or those with advanced stenosis carry greater risk and may have poorer outcomes.

Ultimately you will be the one to decide which treatment option is best for you. Your spine surgeon will discuss all options with you and explain the pros and cons of each to help you decide. Only you can determine if your pain from lumbar spinal stenosis warrants a more definitive treatment plan such as surgery.

Updated on: 01/23/13
Lali Sekhon, MD, PhD, FACS, FAANS
This study gives an excellent overview of what is a very common spinal condition. The etiology, manifestations and management of spinal stenosis are covered very well. A few comments need to be made. Myelography is rarely used as a primary investigative tool with the widespread availability of MR scanning. Minimally-invasive laminectomy is certainly not standard of care in the management of spinal stenosis and most surgeons perform open laminectomies very successfully. In all but experienced hands, complication rates from minimally-invasive laminectomy may be higher than open laminectomy. All patients who are considering surgical intervention or suffer from spinal stenosis should read this thorough and thoughtful review. Fessler et al provide a comprehensive and complete guide to this condition and its management.
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