Biportal Bilateral Transforaminal Endoscopic (TFE) Ventral Decompression in Calcified Lumbar Disc Stenosis: Preliminary Study of 23 patients

Presented at SMISS Annual Forum 2018
By Ajay Krishnan MS Orthopaedics
With Hiroshi Yamada MD, PhD, Mamoru Kawakami MD, PhD, Hiroshi Iwasaki MD, PhD, Akihito Minamide MD, PhD, Masatoshi Teraguchi MD, PhD, Ryohei Kagotani MD, PhD, Shunji Tsutsui MD, PhD, Masanari Takami MD, PhD, Hiroshi Hashizume MD, PhD, Yasutsugu Yukawa MD, PhD,

Disclosures: Ajay Krishnan MS Orthopaedics None Hiroshi Yamada MD, PhD None, Mamoru Kawakami MD, PhD None, Hiroshi Iwasaki MD, PhD None, Akihito Minamide MD, PhD None, Masatoshi Teraguchi MD, PhD None, Ryohei Kagotani MD, PhD None, Shunji Tsutsui MD, PhD None, Masanari Takami MD, PhD None, Hiroshi Hashizume MD, PhD None, Yasutsugu Yukawa MD, PhD None,

Introduction:

Stenosis decompression by posterior approach is the gold standard. Open decompression-discectomy has been reported for calcified disc. TLIF is the most common procedure in view of the calcified disc needing more wider decompression and ventral job. Invasiveness of the procedure has been reduced by tube assisted techniques (MISS). TFE is questioned for its effectiveness but its evolving. Studies are awaited with long term outcomes in stenosis. Biportal bilateral TFE ventral decompression in calcified lumbar disc stenosis has not been reported before in the available literature.

Aims/Objectives:

It is a retrospective study for feasibility and assessment of preliminary outcome of TFE ventral decompression.

Methods:

All cases were done with informed consent and the information of unavailability of standard teaching or literature on TFE for the mentioned disease provided. The inclusion criteria were lumbar degenerative calcified stenosis with or without soft disc herniations with unilateral or bilateral symptoms at L2 to L5/S1 disc levels with complete myelography block. Pure soft disc bulge, protrusion, extrusions and sequestrations were excluded and calcific annulus and/or endplate spur were confirmed. Under local anaesthesia, TFE discectomy and ventral decompression was performed. Both sided inside-out approach was used and if required foraminoplasty added. Some cases with associated soft sequestration necessitated outside-in approach on one side. Carl Storz endoscopic System, Richard Wolf, Maxmore or Joimax system where used with self-designed instruments as well. Adequacy of decompression was confirmed by the visualised dura-roots and MRI confirmation.

Results:

There were 23 patients with minimum follow-up period of 6 months. Statistically significant(p<0.05) ODI and VAS improvements noted without peri-postoperative complications. All patients were day care and job resumption was within 3 weeks. Post-operative MRI showed complete decompression with opening up of myeloblock in 22 cases. One patient had associated dorsal stenosis (Ligamentum flavum) and it took 3 months to improve to Job Activities and MRI did not show complete myeloraphy clearance.

Conclusions:

TFE decompression is the most minimalistic MISS in local anaesthesia and an effective alternative in management of patients with discogenic calcified stenosis. Long term results are awaited. Literature support to challenge the gold standard posterior procedures is scarce and needs validated randomised controlled trials. But, TFE should be considered as a procedure in concentious patients, before more aggressive fusion procedure.