Kashlan Osama Nezar, Kim Hyeun Sung, Khalsa Siri Sahib S, Ravindra Singh, Yong Zhang, Oh Seong Woon, Noh Jeong Hoon, Jang Il-Tae, Oh Seong-Hoon
Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
Department of Neurosurgery, Nanoori Gangnam Hospital, Seoul, Republic of Korea.
Oper Neurosurg (Hagerstown). 2020 Apr 1;18(4):E118-E119. doi: 10.1093/ons/opz162.
Nerve root compression by foraminal pathology is challenging for a surgeon to decompress without violating the facet joint, which may necessitate a fusion procedure. One nonfusion approach to foraminal pathology is a combination intracanal approach for a laminotomy/foraminotomy followed by a paraspinal Wiltse approach for far lateral decompression. Unfortunately, even with the combination approach, it continues to be difficult to achieve adequate decompression without violating much of the facet joint overlying the nerve root. Spine endoscopy offers the ability to decompress the foraminal portion of the nerve without significant violation of the facet joint. We present a surgical video describing the technique for performing a percutaneous endoscopic contralateral L5-S1 foraminal decompression via an interlaminar approach, for a patient presenting with a left L5 radiculopathy due to L5-S1 foraminal stenosis. We explain the differences in the endoscopic channel docking point between ipsilateral and contralateral interlaminar approaches. The steps of an endoscopic foraminotomy are then described: dissect soft tissue and ligamentum flavum off the medial left S1 lamina and superior articulating process (SAP), undercut the superior articulating process of S1 and the inferior articulating process (IAP) of L5 with a drill, resect lateral ligamentum flavum off SAP and IAP exposing epidural fat, and finally dissect the left L5 nerve root and remove compressive lesions throughout its course in the lateral recess, foramen, and laterally. The presentation ends with an intraoperative photograph showing a decompressed L5 nerve root and postoperative imaging confirming this decompression. Appropriate patient consent was obtained.
椎间孔病变导致的神经根受压，对于外科医生而言，在不侵犯小关节的情况下进行减压具有挑战性，这可能需要进行融合手术。一种针对椎间孔病变的非融合方法是联合椎管内入路进行椎板切开术/椎间孔切开术，随后采用经椎旁Wiltse入路进行极外侧减压。不幸的是，即便采用联合入路，在不大量侵犯覆盖神经根的小关节的情况下，仍难以实现充分减压。脊柱内镜能够在不显著侵犯小关节的情况下对神经根的椎间孔部分进行减压。我们展示了一段手术视频，描述了通过椎板间入路对一名因L5 - S1椎间孔狭窄导致左侧L5神经根病的患者进行经皮内镜下对侧L5 - S1椎间孔减压的技术。我们解释了同侧和对侧椎板间入路在内镜通道对接点上的差异。接着描述了内镜下椎间孔切开术的步骤：从左侧S1椎板内侧和上关节突（SAP）剥离软组织和黄韧带，用钻头在S1上关节突和L5下关节突（IAP）下方进行咬骨，从SAP和IAP切除外侧黄韧带，暴露硬膜外脂肪，最后解剖左侧L5神经根并在其走行全程的外侧隐窝、椎间孔及外侧去除压迫性病变。演示以一张术中照片结束，照片显示L5神经根已减压，术后影像学检查证实了这一减压效果。已获得患者的适当知情同意。
