Percutaneous endoscopic transforaminal approach to decompress the lateral recess in an elderly patient with spinal canal stenosis, herniated nucleus pulposus and pulmonary comorbidities

Abstract

A 70-year-old man with severe pulmonary comorbidities was referred to our institution for treatment of a right L5 nerve impingement. He had suffered from spinal canal stenosis and herniated nucleus pulposus (HNP) at the level of L4-L5 for more than a year and had been treated conservatively. However, the pain could not be alleviated, and his primary care physician scheduled posterior decompression surgery. During this procedure, the anesthesiologist refused to induce general anesthesia because of the patient's very poor pulmonary condition. Subsequently, the patient was referred to us. We used a transforaminal approach with percutaneous endoscopic discectomy, with the patient under local anesthesia. First, herniated nucleus pulposus fragments at the disc level were removed. With a trephine drill, the upper part of the L5 pedicle was removed, which allowed for the extraction of dorsally migrated fragments. Following complete removal of the herniated nucleus pulposus fragments, osseous decompression was performed. The osseous endplate of L5 (anterior part of the lateral recess) was removed to enlarge the lateral recess so that decompression of the L5 nerve root was possible. The patient's lower back pain and right leg pain subsided following surgery. Percutaneous endoscopic discectomy is useful for patients with severe comorbidities as it can be done with local anesthesia.

Surgery Related Complications in Percutaneous Endoscopic Lumbar Discectomy under Local Anesthesia

“…received. Before he started, he received PED education session with a model bone and an animal spine ; thereafter, he attended PED surgery of the best PED surgeon in this nation, who has a lot of experiences of PED surgery (17)(18)(19)(20), 5 times. In the initial 15 cases, he conducted with guidance by the specialist.…”

A new concept of transforaminal ventral facetectomy including simultaneous decompression of foraminal and lateral recess stenosis: Technical considerations in a fresh cadaver model and a literature review

“…However, this approach basically requires general anesthesia (sometimes epidural anesthesia) because the nerve roots need to be handled and decompressed during surgery. The TF approach, however, can be performed for foraminal stenosis under local anesthesia (14 -17), and this has been of greatest benefit in TF-percutaneous full endoscopic surgery (8,9,31,32). The elderly often have comorbidities (32) rendering them at high risk for general anesthesia, so surgeries that can be done under local anesthesia are preferable in this age group.…”

“…The TF approach, however, can be performed for foraminal stenosis under local anesthesia (14 -17), and this has been of greatest benefit in TF-percutaneous full endoscopic surgery (8,9,31,32). The elderly often have comorbidities (32) rendering them at high risk for general anesthesia, so surgeries that can be done under local anesthesia are preferable in this age group. However, based on anatomic considerations, only the TF approach for foraminal stenosis has been discussed in the literature (14)(15)(16)(17).…”

Percutaneous full endoscopic lumbar foraminoplasty for adjacent level foraminal stenosis following vertebral intersegmental fusion in an awake and aware patient under local anesthesia: A case report

“…First, the surgery can be performed in an awake and aware state under local anesthesia and direct injury to the exiting nerve root can be avoided (23). Further, elderly patients who would normally be considered high-risk for general anesthesia because of comorbid heart, lung, liver, and kidney conditions can be considered for PELF under local anesthesia (24). Second, it is possible to perform PELF without fusion.…”