Name:
10.3171/2024.1.FOCVID23195
Description:
10.3171/2024.1.FOCVID23195
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/0f57f5d6-fab6-429c-a5d4-e59e76a27539/thumbnails/0f57f5d6-fab6-429c-a5d4-e59e76a27539.jpeg
Duration:
T00H09M23S
Embed URL:
https://stream.cadmore.media/player/0f57f5d6-fab6-429c-a5d4-e59e76a27539
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/0f57f5d6-fab6-429c-a5d4-e59e76a27539/4. 23-195.mp4?sv=2019-02-02&sr=c&sig=UwZQHk0duRTEXyaxUrEVjSL0P3SngGc4KUf3IlLvNDk%3D&st=2026-02-07T22%3A53%3A31Z&se=2026-02-08T00%3A58%3A31Z&sp=r
Upload Date:
2026-02-07T22:58:31.8752048Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: The authors present a case
SPEAKER: of navigation-guided endoscopic lumbar decompression on foramen and lateral recess in advanced scoliosis. An 84-year-old female patient presented with left leg radiating pain, anterolateral thigh, for 18 months. On examination, motor on left knee extension was grade 4, with dysesthesia and numbness along the left anterolateral thigh. This video shows how patient walks.
SPEAKER: And she is complaining of left thigh pain. BMD T-score was −3.4. X-ray spine showed a nonprogressive scoliosis from 2011 to 2019. Last Cobb's angle was 58.7 degrees. Preoperative whole- body spine x-ray shows neutral coronal balance with positive sagittal balance, 34.45 mm.
SPEAKER: CT and MRI shows less severe foraminal and lateral recess stenosis on L3–4 level with diffuse bulging disc and ligament flavum thickening. Left lateral recess might pinch L4 traversing root. CT and MRI on L4–5 and L5–S1 level also show foraminal stenosis but not as severe as L3–4 level. Diagnosis was made based on clinical and radiological findings.
SPEAKER: Patient symptoms is on L3–4 dermatome and from imaging shows severe foraminal and lateral recess stenosis on left L3–4 level and severe degree scoliosis. Diagnostic root block is performed to confirm pain generators. The main purpose for treatment is treating the pain generator. Endoscopic decompression on the left L3–4 level is preferred over deformity correction. We preferred decompression surgery rather than fusion surgery because of several factors in patient, such as old age, poor bone quality, medical comorbidities, and pain generator, it seems, due to compression of left L3–4 nerve root.
SPEAKER: Patient underwent endoscopic transforaminal foraminotomy and lateral recess decompression on the left L3–4 level, under general anesthesia and in a prone position. We use a navigation system to enhance accuracy of planned decompression targets. Reference frame was attached to patient's back using tape. This frame serves as a reference point for the navigation system throughout the procedure. Left L3–4 foramen was checked with O-arm navigation system.
SPEAKER: Vertical 1-cm incision was made at desired level 4 to 5 cm from midline. After incision was made, obturator was inserted. We use a 5.5 working channel. Before introduce endoscope, we reconfirm left L3–4 foramen with O-arm navigation system. We calibrate and attach navigation tracker to our surgical instruments.
SPEAKER: This ensures that the system accurately tracks the position and orientation of these instruments in real time during the surgery. After that, we introduce endoscope and connect water system. We use 20-degree endoscope. Navigation tracker is attached to endoscope instrument. This is the initial endoscopic view of paraspinal muscle after docking.
SPEAKER: Muscle dissection was performed using a radiofrequency probe to resect the overlying muscle to identify the bone landmarks. By using a beveled edge of the working channel, we can dissect using a rotating maneuver. After muscle dissection, the bony structures of pars and SAP were exposed. Lateral aspect of pars was drilled.
SPEAKER: Further dissection targeted the junction of the lateral border of the pars and the transverse process. The inferior edge of the L3 transverse process was meticulously dissected. Subsequently, drilling of the transversus and pars junction was conducted using a diamond burr, including the inferior part of the L3 transverse process. After drilling, wider space was obtained for introducing endoscope into the foramen.
SPEAKER: To make foraminal space wider, we drilled lateral border of pars, medial part of transverse process, and pars junction L3. Resection of transverse process and soft tissue was performed using Kerrison punches. In the video, we can see the proper technique for securely holding and rotating the endoscope with left hand.
SPEAKER: Additionally, right index and middle fingers were positioned on the endoscope to control the depth of the drill. Then pars was drilled to expose the dorsal surface of nerve. Posterior aspect of nerve root was exposed. Using dissector, foraminal ligament was detached from the transverse process. And we can assess the edge of pars drilled.
SPEAKER: Resection of transverse process was performed using Kerrison punches to expose the nerve root. Since there was a severe adhesion, care was taken when removing the transverse process and pars over the nerve root.
SPEAKER: We're assessing the extent of transverse process resection to help ensure adequate removal to relieve compression on the nerve roots and avoid overresection. The caudal part of SAP was drilled to decompress lateral recess. And superficial layer of ligamentum flavum was cut. Ligamentum flavum was removed in piecemeal fashion. Ligamentum flavum over the traversing root, also being resected.
SPEAKER: Dissection and resection of ligamentum flavum was performed at the exit portion of traversing root and exiting root. A bit more of caudal and medial part of transverse process is removed to unroof exiting root from proximal to distal part. Then to decompress traversing root, we dissect and remove the ligamentum flavum, also in piecemeal fashion.
SPEAKER: Fibrous band and neural structure in the shoulder region of traversing root are being dissected. Decompressing the distal portion of exiting root was performed. The remnant ligamentum flavum in the distal portion of the exiting root was removed using a Kerrison and trunk using a radiofrequency probe.
SPEAKER: Using curved hook, lateral and medial wall of pedicle was palpated to confirm sufficient decompression of the proximal portion of the exiting nerve root. We perform annuloplasty using radiofrequency probe for annular sealing. Remnant ligamentum flavum was removed for decompressing distal portion of the nerve root.
SPEAKER: Ligamentum flavum was dissected and excised to decompress traversing root. Finally, lateral recess decompression was accomplished, ensuring a comprehensive approach to traversing root decompression. Subcutaneous suture was done on skin incision. Length of surgery was 1 hour and 30 minutes.
SPEAKER: Estimated blood loss was 20 ml. The patient exhibited improved left leg pain postoperatively, with the ability to ambulate just a few hours after surgery. Notably, there were no intraoperative complications. Postoperative x-ray and CT scans revealed an increased foraminal space, affirming the positive impact of the surgical intervention. The 3-year postoperative follow-up indicates that the pain has disappeared and the patient has achieved an excellent outcome and satisfaction score.
SPEAKER: Whole-spine x-ray also shows well-maintained coronal and sagittal alignment over 3 years after surgery. Thank you.
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