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Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia

BACKGROUND: The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.(1–6) The or...

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Autores principales: Yeung, Anthony, Gore, Satishchandra
Formato: Online Artículo Texto
Lenguaje:English
Publicado: International Society for the Advancement of Spine Surgery 2014
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4325507/
https://www.ncbi.nlm.nih.gov/pubmed/25694939
http://dx.doi.org/10.14444/1022
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author Yeung, Anthony
Gore, Satishchandra
author_facet Yeung, Anthony
Gore, Satishchandra
author_sort Yeung, Anthony
collection PubMed
description BACKGROUND: The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.(1–6) The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.(7) METHODS: Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).(8, 9) The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI. RESULTS: The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery. CONCLUSIONS / LEVEL OF EVIDENCE 3: The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.(10) The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.(11) It also avoids going through the previous surgical site. CLINICAL RELEVANCE: Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.(12) Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS.
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spelling pubmed-43255072015-02-18 Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia Yeung, Anthony Gore, Satishchandra Int J Spine Surg Article BACKGROUND: The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.(1–6) The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.(7) METHODS: Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).(8, 9) The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI. RESULTS: The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery. CONCLUSIONS / LEVEL OF EVIDENCE 3: The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.(10) The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.(11) It also avoids going through the previous surgical site. CLINICAL RELEVANCE: Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.(12) Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS. International Society for the Advancement of Spine Surgery 2014-12-01 /pmc/articles/PMC4325507/ /pubmed/25694939 http://dx.doi.org/10.14444/1022 Text en Copyright © 2014 ISASS - International Society for the Advancement of Spine Surgery http://creativecommons.org/licenses/by-nc-nd/3.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Article
Yeung, Anthony
Gore, Satishchandra
Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia
title Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia
title_full Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia
title_fullStr Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia
title_full_unstemmed Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia
title_short Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia
title_sort endoscopic foraminal decompression for failed back surgery syndrome under local anesthesia
topic Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4325507/
https://www.ncbi.nlm.nih.gov/pubmed/25694939
http://dx.doi.org/10.14444/1022
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