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59 Microsurgical Decompression
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adjacent laminae and the part of the base of the spinous
process is performed (Fig.59.9).
• The next step is the resection of the contralateral ligamentum avum and the subarticular decompression until the
lateral border of the dura and the medial border of the
contralateral inferior pedicle are identied. In cases with
severe stenosis, the dura should be separated from the
ligamentum avum with blunt dissection before resection
to avoid cerebrospinal uid leak.
• The adequate decompression should be checked with a
blunt probe.
• Check the bone margins with a blunt dissector to be certain that no sharp bony spicules remain (which can penetrate the dura postoperatively).
• Meticulous hemostasis and wound closure.
59.7 Postoperative Care
• Bed rest for 6 h in supine position with elevated chest
(30°) to elevate lumbar CSF pressure for compression of
epidural veins.
• We recommend bracing only in cases with more than twolevel decompression.
References
1. Berney J.Epidemiology of narrow spinal canal. Neurochirurgie.
1994;40:174–8.
2. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br.
1954;36-B:230–7.
3. Verbiest H. Pathomorphologic aspects of developmental lumbar
stenosis. Orthop Clin North Am. 1975;5:177–96.
4. Amundsen T, Weber H, Nordal HJ, etal. Lumbar spinal stenosis:
conservative or surgical management? A prospective 10-year study.
Spine. 2000;25:1425–35.
5. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis
with spinal stenosis. A prospective study comparing decompression
with decompression and intertransverse process arthrodesis. J Bone
Joint Surg Am. 1991;73:802–8.
6. Silvers HR, Lewis PJ, Ash HL.Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg. 1993;78:695–701.
7. Hopp E, Tsou PM. Postdecompression lumbar instability. Clin
Orthop Relat Res. 1988;227:143–51.
8. McCulloch JA.Microsurgery for lumbar spinal canal stenosis. In:
McCulloch JA, Young PH, editors. Essentials of spinal microsurgery. Philadelphia: Lippincott-Raven; 1998. p.453–86.
9. Poletti CE.Central lumbar stenosis caused by ligamentum avum:
unilateral laminotomy for bilateral ligamentectomy. Preliminary
report of two cases. Neurosurgery. 1995;37:343–7.
10. Senegas J, Etchevers JP, Vital JM, et al. Recalibration of the
lumbar canal, an alternative to laminectomy in the treatment of
lumbar canal stenosis. Rev Chir Orthop Reparatrice Appar Mot.
1988;74:15–22.
Endoscopic Lumbar Disk Surgery
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SebastianRuetten
60
60.1 Introduction and Core Messages
Minimally invasive techniques can reduce tissue damage and its consequences. Endoscopic operations are
now considered standard in certain areas. The most
common full endoscopic technique for patients with
lumbar disk afictions is the posterolateral transforaminal operation. Laser and bipolar radiofrequency current
can be used. Removal of intra- or extraforaminal disk
herniations is technically possible. Resection of herniations within the spinal canal—in the sense of a retrograde removal from intradiscal through the existing
annulus defect—has been described. Nevertheless, difculties in the resection of herniated discs located within
the spinal canal cannot always be completely ruled out.
Using the lateral transforaminal access, the spinal canal
can be more sufciently reached under continuous visualization. Even so, the bony borders of the foramen and
the exiting nerve may limit mobility and thus the resection of dislocated disk material. In addition, the pelvis
and abdominal organs may hinder access. Thus, there
may be limitations for the transforaminal procedure.
The full endoscopic interlaminar access was developed
to enable operation of pathologies outside the indication
spectrum for the transforaminal procedure. The combination of new operative accesses with the technical
advances now enables for the rst time a full endoscopic
procedure with visual control, which is equal to conven-
tional operations when the indication criteria are heeded.
Basically, the transforaminal procedure has more limitations than the interlaminar, but at the same time, it is less
tissue traumatic.
60.2 Indication
60.2.1 General Indications
The indication for operation corresponds to current valid
standards [1]. The greatest experience has been gained in the
therapy of herniated discs and lateral spinal canal stenoses
[2–6]. Existing secondary pathologies, such as instabilities,
must possibly be treated at the same time with other procedures. The following indications are currently unequivocal
(Figs.60.1, 60.2, and 60.3):
• Sequestered or nonsequestered lumbar disk herniations,
independent of localization
• Recurrent disk herniations after conventional or full endo-
scopic operations
• Lateral bony and ligamentary spinal canal stenoses
• In special cases, cysts of the zygapophyseal joint
• In special cases, positioning of implants in the interverte-
bral space
• In special cases, intervertebral debridement and draining
in spondylodiscitis
S. Ruetten (*)
Department of Orthopädic Surgery, Center for Spine Surgery and
Pain Therapy, Center for Orthopaedics and Traumatology,
St. Anna-Hospital, Herne, Germany
e-mail: spine-pain@annahospital.de;
spine-pain@elisabethgruppe.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_60
60.2.2 Indication forTransforaminal Approach
All intra- and extraforaminal disk herniations are taken as
indications for the transforaminal approach. In disk herniations within the spinal canal, the following inclusion criteria
must be heeded due to the limited mobility [3–6]:
• Sequestration toward cranial maximal to the start of the
pedicle above, toward caudal maximal to the middle of
the pedicle below the level in question
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Fig. 60.1 Posterolateral
transforaminal approach
S. Ruetten
Fig. 60.2 Lateral
transforaminal approach
• In orthograde lateral ray path, pelvic overlay of the level
in question maximal to the middle of the pedicle
Note: In lateral spinal canal stenoses, the craniocaudal
extension should reach maximal from the upper edge of the
pedicle below to the lower edge of the pedicle above the level
in question. In applying the usually necessary lateral
approach, the access pathway may not be shifted by abdominal structures. This is especially to be heeded in the levels
cranial to L3/4. If the nding is not entirely clear, a single
abdominal CT scan should be made through the disk for
evaluation and preoperative planning.
60.2.3 Indication forInterlaminar Approach
• All disk herniations located within the spinal canal, which
cannot be operated technically in the transforaminal
approach because of the criteria cited, are taken as indications for the interlaminar approach [2–5].
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60.5 Planning, Preparation, andPositioning
As with all microsurgical techniques, the intraoperative procedure must be planned preoperatively based on imaging
ndings. The goal is to perform the resection of spinal canal
structures as sparingly as possible depending on the pathology. Full endoscopic operations can usually be performed
under general anesthesia. This is more comfortable for both
the patient and the surgeon, enables positioning as needed,
and also makes extensive work within the spinal canal possible. The operations are performed with the patient in prone
position on an X-ray permeable table, under orthograde
radiological control at two levels. The patient lies on a hip
and thorax roll to relieve the abdominal and thoracic organs.
The operation table can be adjusted intraoperative lumbar
either lordotic or kyphotic depending on the anatomy and
pathology. A single-shot antibiosis is applied for infection
prophylaxis.
60.6 Operating Technique
Fig. 60.3 Interlaminar approach
60.3 Contraindications
• All criteria, which generally apply as contraindications
to decompressing operations, taking into consideration
the specic technical possibilities and the inclusion criteria of each surgical procedure, are considered
contraindications.
60.4 Technical Prerequisites
An X-ray permeable, electrically adjustable operation table
and a C-arc are necessary. In addition to the surgical instruments and optics, general equipment for endoscopic operations under uid ow are needed, such as monitor, camera
unit, light source, documentation system, uid pump, shaver
system, or radio-frequency generator. Equipment available
for arthroscopy or endoscopy can be used.
60.6.1 Transforaminal Approach [3–6]
• First, the skin incision is localized. The goal is to reach
the spinal canal as tangentially as possible. At levels L4/5
and L3/4, in lateral ray path, the dorsal line of the descending facet usually serves as the boundary, which should not
be crossed toward ventral. To avoid injury to abdominal
organs, a single abdominal CT scan through the individual disk should be made for evaluation and preoperative
planning, especially in the cranial levels when ndings
are not unequivocal. Depending on the scan, an individual, less lateral approach should be selected.
• A 1.5-mm atraumatic spinal needle is inserted through
the skin incision orthograde to the disk space in the target area (Fig. 60.4). After a 0.8-mm target wire is
inserted and the cannula removed, the cannulated dilator
is inserted.
• The target wire is removed, and the 7.9-mm operation
sheath with beveled opening is pushed through the dilator
(Figs.60.5 and 60.6). From this point on, decompression
is made under visualization and continuous irrigation
with isotonic saline without any special additives.
• Further entry into the epidural space, which may be
required, is made under visual control. If the bony diameter of the foramen does not permit passage, the foramen
is widened with a burr and instruments.
• If the position of the exiting nerve is not clear, for example, in intra- or extraforaminal herniation or foraminal
stenosis, an extraforaminal access is created on the caudal
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S. Ruetten
Fig. 60.4 Example of the end position of the operation sheath AP in
the spinal canal
Fig. 60.5 The opening of the operation sheath is in the epidural space
pedicle as a safe zone, and further preparation toward the
pathology is made under visual control (see Fig.60.7).
• The precise performance of decompression depends on
the nding in each case.
60.6.2 Interlaminar Approach [2–5]
• The skin incision is made as medial as possible over the
interlaminar window. The craniocaudal localization
depends on the ndings of the pathology in question.
• The dilator is inserted bluntly on the lateral edge of the
ligamentum avum or on the descending facet of the zygapophyseal joint.
Fig. 60.6 Full endoscopic transforaminal operation
Fig. 60.7 Start of the extraforaminal operation on the caudal pedicle
outside the foramen
• The 7.9-mm operation sheath with beveled opening is
inserted via the dilator in the direction of the ligament
(see Fig.60.8).
• From this point on, the further procedure is performed
under visualization and continuous irrigation with isotonic saline solution without any special additive. To
reach the spinal canal, the ligamentum avum is incised
lateral to ca. 3–5mm.
• The further procedure is enabled by the elasticity of the
ligament (see Figs.60.9 and 60.10).
60 Endoscopic Lumbar Disk Surgery
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Fig. 60.8 Inserted dilator with operation sheath
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Fig. 60.11 Rotation of the operation sheath
Fig. 60.9 Lateral incision of the ligamentum avum
Fig. 60.10 Identication of the anatomical structures
Fig. 60.12 Full endoscopic interlaminar operation
• The operation sheath with beveled opening can be used as
a second instrument by rotation and serves, for example,
as a nerve hook in shifting the neural structures toward
medial (see Figs.60.11 and 60.12).
• If the bony diameter of the interlaminar window does
not permit passage or in the operation of a spinal canal
stenosis, the window is enlarged using a burr and
instruments.
• In cases of clearly dislocated sequesters, which cannot be
completely reached from a level without more extensive
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S. Ruetten
bone resection, consideration can be given to creating
another access later via the neighboring interlaminar
window.
• The precise performance of the decompression depends
on the ndings in each case.
60.7 Possible Complications
Possible complications during microsurgical procedures
are known, and there are numerous publications [7–10]. A
minimally invasive procedure can reduce the complication
rate, though statistically, it cannot be completely avoided
[11, 12]. In principle, all of the complications are possible,
which are known in conventional operating procedures
[2–6]. With respect to the full endoscopic procedures, it
must be emphasized that a one- or two-sided switch to an
open procedure may be necessary for the therapy of a complication. Especially, endoscopic suture of a dural injury is
technically not possible. Theoretically, in long operating
times and overlooked blockage of the outow of irrigation
uid, the consequences of increased pressure within the
spinal canal and the attached and neighboring structures
cannot be completely ruled out. In the interlaminar
approach, a long-lasting and uninterrupted excessive
retraction of the neural structures with the working sheath
toward medial must be avoided or made only intermittently in order to avoid the risk of neurological damage. In
the transforaminal approach, the risk of injury to the exiting nerves cannot be completely ruled out. In using the
lateral access, it must be ruled out that abdominal organs
block the path of access. Especially during the learning
curve, experience has shown that there is an increased risk
that complications will occur, as is the case in any new
technique.
References
1. Andersson GBJ, Brown MD, Dvorak J, etal. Consensus summary
on the diagnosis and treatment of lumbar disc herniation. Spine.
1996;21:75–8.
2. Ruetten S, Komp M, Merk H, etal. Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach
versus conventional microsurgical technique: a prospective, randomized, controlled study. J Neurosurg Spine. 2009;10:476–85.
3. Ruetten S, Komp M, Merk H, etal. Recurrent lumbar disc herniation following conventional discectomy: a prospective, randomized
study comparing full-endoscopic interlaminar and transforaminal
versus microsurgical revision. J Spinal Disord Tech. 2009;22:122–9.
4. Ruetten S, Komp M, Merk H, etal. Full-endoscopic interlaminar
and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study.
Spine. 2008;33:931–9.
5. Ruetten S, Komp M, Merk H, et al. Use of newly developed
instruments and endoscopes: full-endoscopic resection of lumbar
disc herniations via the interlaminar and lateral transforaminal
approach. J Neurosurg Spine. 2007;6:521–30.
6. Ruetten S, Komp M, Godolias G.An extreme lateral access fort the
surgery of lumbar disc herniations inside the spinal canal using the
full-endoscopic uniportal transforaminal approach—technique and
prospective results of 463 patients. Spine. 2005;30:2570–8.
7. Ramirez LF, Thisted R. Complications and demographic characteristics of patients undergoing lumbar discectomy in community
hospitals. Neurosurgery. 1989;25:226–31.
8. Rompe JD, Eysel P, Zollner J.Intra- and postoperative risk analysis
after lumbar intervertebral disk operation. Z Orthop Ihre Grenzgeb.
1999;137:201–5.
9. Stolke D, Sollmann WP, Seifert V.Intra- and postoperative complications in lumbar disc surgery. Spine. 1989;14:56–9.
10. Wildfoerster U. Intraoperative complications in lumbar intervertebral disc operations. cooperative study of the spinal study
group of the German Society of Neurosurgery. Neurochirurgica.
1991;34:53–6.
11. Schick U, Doehnert J, Richter A, etal. Microendoscopic lumbar
discectomy versus open surgery: an intraoperative EMG study. Eur
Spine J. 2002;11:20–6.
12. Weber BR, Grob D, Dvorak J, et al. Posterior surgical approach
to the lumbar spine and its effect on the multidus muscle. Spine.
1997;22:1765–72.
Translaminar Screw Fixation
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StefanSchären
61.1 Introduction and Core Messages
Translaminar screws (TLSs) were developed by
F.Magerl in 1980 as an evolution to the transarticular
screws rst published by D. King in 1948 and later
modied by H.Boucher in 1959 [1–3]. Compared to
these precursors, TLSs have a longer trajectory in bone
blocking the facet joints as setscrews more efciently
[4, 5]. Since the screw directory runs tangentially to
the exiting nerve root, the risk for injury is minimal.
Compared to pedicle screws, TLS yields inferior biomechanical stability especially in exion and rotation
[6, 7]. With pedicle screws nowadays being the gold
standard for posterior instrumentation, TLS remains an
elegant and cost-effective method for selected cases.
The translaminar screw xation is a safe and effective
method for posterior stabilization of one or two motion
segments. It is mostly used supplementary to anterior
fusion techniques and can effectively stabilize one or
two motion segments in conjunction with anterior
instrumentation [8, 9]. This technique is contraindicated in anterior column defect.
61
• In combination with pedicle instrumentation for long-
range fusion (see Fig.61.1)
61.3 Contraindications
• Missing posterior elements, for example, after
laminectomy
• Missing anterior support, for example, fracture and
tumor
• Fusion of three and more levels
• Severe osteoporosis
61.4 Technical Prerequisites
Fluoroscopy, positioning device (e.g., Relton Hall frame),
4.5-mm cortical screws in various lengths (usually
45–55mm), preferably in titanium for better MRI compatibility (e.g., Synthes GmbH, Solothurn, Switzerland), long
3.2-mm drill and drill sleeve, and long tab. Alternatively, car-
bon/PEEK pins can be used (Signus GmbH, Alzenau,
Germany) (see Fig.61.2).
61.2 Indications
Stabilization in degenerative disorders with mainly intact
posterior elements:
• Posterior fusion of one or two motion segments from T12
to S1
• Supplementary to anterior interbody fusion
S. Schären (*)
Department of Orthopaedic Surgery/Spine, University Hospital,
Basel, Switzerland
e-mail: sschaeren@uhbs.ch
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_61
61.5 Surgical Technique
61.5.1 Approach
A standard midline posterior approach is performed with
subperiosteal exposure of the spinous processes, laminae,
and transverse processes. The joint capsules of the motion
segments to be fused are resected, and the bony elements are
thoroughly cleaned using a chisel. In order not to compromise the bony elements, which are important for the TLS, a
formal decortication should not be performed. In case of spinal stenosis or disk hernia, decompressive laminotomy or
discectomy is added, preserving the lamina.
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S. Schären
Fig. 61.1 (a, b) A 47-year-old woman with candida spondylodiscitis
L4/5 with severe destruction of the adjacent end plates was treated with
posterior transpedicular stabilization L3/S1, anterior debridement, and
fusion L4/5 using iliac crest autograft followed by antimycotic treat-
ment. Translaminar screws L3/4 and L4/5 were used, avoiding the
insertion of transpedicular screws penetrating into the infected vertebral bodies of L4 and L5. AP and lateral radiographs 24months postoperatively show solid fusion and stable implants
61.6 Instrumentation
Fig. 61.2 ECF (endless carbon ber) PEEK translaminar pin (With
permission from Signus GmbH, Alzenau, Germany)
• The rst screw hole is drilled starting cranially from the
base of the spinous process aiming toward the inferior border of the opposite transverse process. The drill subcortically passes the contralateral lamina, crosses the facet
joint, and penetrates the cortex of the transverse process
(Fig.61.3).
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Fig. 61.3 Direction of a long 3.2-mm drill bit, protected with a drill
sleeve
• After measuring the screw length, the hole is tabbed
shortly across the facet joint taking care not to penetrate
the outer cortex.
• The corresponding 4.5-mm titanium cortical screw is
inserted until the screw head has contact with the spinous
process (Fig.61.4).
• The second screw hole is drilled running posterior to the
rst screw through the opposite lamina.
• After measuring and tabbing, a second screw is inserted
(Figs.61.5, 61.6, and 61.7).
Fig. 61.4 Insertion of the 4.5-mm cortical screw of appropriate length
• In case of posterior fusion, the posterior elements are covered with bone graft (e.g., from the iliac crest).
61.7 Tips andTricks
• In the event of a deep situs and abundant soft tissues, it is
possible to drill and insert the screw percutaneously using
a troikar system.
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