Combined Effects of Graded Foraminotomy and Annular Defect on Biomechanics after Percutaneous Endoscopic Lumbar Decompression: A Finite Element Study.

Percutaneous endoscopic technology has been widely used in the treatment of lumbar disc stenosis and herniation. However, the quantitative influence of percutaneous endoscopic lumbar decompression on spinal biomechanics of the L5-S1 lumbosacral segment remains poorly understood. Hence, the objective of this study is to investigate the combined effects on the biomechanics of different grades of foraminotomy and annular defect for the L5-S1 segment. A 3D, nonlinear, detailed finite element model of L4-S1 was established and validated. Changes in biomechanical responses upon stimulation to the intact spine during different degrees of resection were analyzed. Measurements included intervertebral rotation, intradiscal pressure, and the strain of disc structure under flexion, extension, left/right lateral bending, and left/right axial rotation under pure bending moments and physiological loads. Compared with the intact model, under prefollower load, annular defect slightly decreased intervertebral rotation by -5.0% in extension and 2.2% in right axial rotation and significantly increased the mean strain of the exposed disc by 237.7% in all loading cases. For right axial rotation, unilateral total foraminotomy with an annular detect increased intervertebral rotation by 29.5% and intradiscal pressure by 57.6% under pure bending moment while the maximum corresponding values were 9.8% and 6.6% when the degree of foraminotomy was below 75%, respectively. These results indicate that percutaneous endoscopic lumbar foraminotomy highly maintains spinal stability, even if the effect of annular detect is taken into account, when the unilateral facet is not totally removed. Patients should avoid excessive extension and axial rotation after surgery on L5-S1. The postoperative open annular defect may substantially increase the risk of recurrent disc herniation.