Posterior decompression surgery for extraforaminal entrapment of the fifth lumbar spinal nerve at the lumbosacral junction

Abstract

Object: In this paper, the authors' goal was to elucidate the clinical features and results of decompression surgery for extraforaminal stenosis at the lumbosacral junction.

Methods: Twenty-eight patients with severe leg pain caused by extraforaminal stenosis at the lumbosacral junction (18 men and 10 women; mean age 68.2 +/- 8.9 years) were treated by posterior decompression without fusion using a microendoscope in 19 patients and a surgical microscope or loupe in 9 patients. The decompression procedures consisted of partial resection of the sacral ala, the L-5 transverse process, and the L5-S1 facet joint along the L-5 spinal nerve. The following items were investigated: 1) preoperative neurological findings; 2) preoperative radiological findings, including plain radiographs, CT scans, selective radiculography of L-5; 3) surgical outcome as evaluated using the Japanese Orthopaedic Association scale for low-back pain (JOA score); and 4) need for revision surgery.

Results: All patients presented with neurological deficits compatible with a diagnosis of L-5 radiculopathy such as weakness of the extensor hallucis longus muscle and sensory disturbance in the L-5 area together with neurogenic claudication. On plain radiographs, 21 patients (75%) and 17 patients (60.7%) exhibited lumbar scoliosis (>or= 5 degrees) and wedging of the L5-S1 intervertebral space (>or= 3 degrees), respectively. The CT scans demonstrated marked osteophyte formation at the posterolateral margin of the L5-S1 vertebral bodies, and a selective L-5 nerve root block was effective in all patients. All patients reported pain relief immediately after surgery. The mean JOA scores were 11.3 +/- 3.8 before surgery and 24.3 +/- 3.4 at the time of the final follow-up examination; the recovery rate was 68.6 +/- 16.5%. The mean estimated blood loss was 66.6 +/- 98.6 ml, and the mean surgical time was 135.3 +/- 46.5 minutes. No significant difference in the recovery rate of the JOA scores or in the surgical time and blood loss was observed between the 2 surgical approaches. Four patients underwent revision posterior interbody fusion for the recurrence of radicular pain as a result of intraforaminal stenosis in 3 patients and insufficient decompression of the extraforaminal area in the remaining patient at an average of 19.5 months after surgery.

Conclusions: Extraforaminal stenosis at the lumbosacral junction is a rare but distinct pathological condition causing L-5 radiculopathy. Decompression surgery without fusion using a microendoscope or a surgical microscope/loupe is a feasible and less invasive surgical option for elderly patients with extraforaminal stenosis at the lumbosacral junction.