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, 16 (1), 138-147

Biportal Endoscopic Spinal Surgery for Bilateral Lumbar Foraminal Decompression by Switching Surgeon's Position and Primary 2 Portals: A Report of 2 Cases With Technical Note

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Biportal Endoscopic Spinal Surgery for Bilateral Lumbar Foraminal Decompression by Switching Surgeon's Position and Primary 2 Portals: A Report of 2 Cases With Technical Note

Kwan-Su Song et al. Neurospine.

Abstract

Total facetectomy with/without fusion and facet-preserving microforaminotomy have been performed as conventional surgical treatments for lumbar foraminal stenosis (LFS). Recently, endoscopic spinal surgery has been introduced as a minimally invasive therapeutic modality of LFS by several authors. We report two cases of bilateral LFS at lumbosacral junction level successfully treated with a novel biportal endoscopic spine surgery (BES) technique using primary 2 portals. Two patients presented with chronic onset of back pain and neurogenic claudication symptom. They were diagnosed with bilateral LFS at L5-S1 level from magnetic resonance imaging and computed tomography preoperatively. BES for bilateral foraminal decompression was performed via contralateral approach bilaterally without additional skin incision or surgical trajectory by switching surgeon's position and primary 2 portals. After the surgery, preoperative patients' back and leg pain resolved and unilateral leg weakness of the 2 patients gradually improved in a few months. Postoperative radiologic images revealed significantly enlarged bilateral foramens at L5-S1 level.

Keywords: Bilateral lumbar foraminal stenosis; Biportal endoscopic spine surgery; Contralateral approach; Minimal invasive.

Conflict of interest statement

The authors have nothing to disclose.

Figures

Fig. 1.
Fig. 1.
Pre- and postoperative radiologic images of the first case. (A) Preoperative parasagittal T2-weighted magnetic resonance imaging (MRI) image. (B) Preoperative axial T2-weighted MRI image. (C) Preoperative axial computed tomography (CT) image. (D) Postoperative parasagittal T2-weighted MRI image. (E) Postoperative axial. (F) Postoperative axial CT image of resected superior articular process. Black circles: compressed areas of bilateral L5 nerve root by L5–S1 foraminal stenosis. White circles: decompressed foraminal areas for bilateral L5 exiting roots. White arrows: resected areas of bilateral superior articular process of S1.
Fig. 2.
Fig. 2.
Pre- and postoperative radiologic images of the second case. (A) Preoperative parasagittal T2-weighted magnetic resonance imaging (MRI) image. (B) Preoperative axial T2-weighted MRI image. (C) Preoperative axial computed tomography (CT) image. (D) Postoperative parasagittal T2-weighted MRI image. (E) Postoperative axial T2-weighted MRI image. (F) Postoperative axial CT image. Black circles: compressed areas of bilateral L5 nerve root by L5-S1 foraminal stenosis. White circles: decompressed foraminal areas for bilateral L5 exiting roots. White arrows: resected areas of bilateral superior articular process of S1.
Fig. 3.
Fig. 3.
Equipment used in percutaneous biportal endoscopic surgery with switching technique. 0° 3-mm diameter arthroscope (1), 3-mm unhooded barrel bur (2), 3-mm unhooded round bur (3), 5-mm shaver (4), 3.5-mm bendable diamond burs (5), chisels: 5-mm width chisel, straight (6), straight (7) and 40° angled (8), curettes: 90° (9), right angled (10, 11), up (12) and downward (13) directed, 90°, 3.75-mm radiofrequency probe (14), 30° 1.4-mm microblator radiofrequency probe (15).
Fig. 4.
Fig. 4.
Initial placement of two portals and related anatomy. (A) Skin marking for the placement of 2 portals. (B) Position of 2 portals on anteroposterior view of X-ray. Yellow circle: the site for placement of cranial portal. Red circle: the site for placement of caudal portal.
Fig. 5.
Fig. 5.
Operative illustrations in endoscopic view. (A) Thecal sac and shoulder margin of contralateral traversing root was revealed. (B) Cranial tip of superior articular process (S1) is cut by angled chisel. (C) Decompressed L5 exiting root in contralateral side (left) is observed. (D) Decompressed L5 exiting root in primary ipsilateral side (right) is demonstrated. Black triangle: cranial tip of superior articular process. Asterisk: L5 exiting root (contralateral). White arrow: L5 exiting root (ipsilateral).
Fig. 6.
Fig. 6.
Foraminal decompression by resection of cranial tip of superior articular process.
Fig. 7.
Fig. 7.
Schematic illustration of operative setup and intraoperative angle of scope and instruments. (A) Contralateral approach from primary ipsilateral side (before switching). (B) Contralateral approach to primary ipsilateral side from switched contralateral side (after switching of operator’s position and exchange of 2 portals).
Fig. 8.
Fig. 8.
Postoperative wound. (A) Immediately after operation. (B) Seven days after operation.

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