Decompression Using Minimally Invasive Surgery for Lumbar Spinal Stenosis Associated with Degenerative Spondylolisthesis: A Review

Abstract

Lumbar spinal stenosis (LSS), which often occurs concurrently with degenerative spondylolisthesis (DS), is a common disease in the elderly population, affecting the quality of life of aged people significantly. Notwithstanding the frequently good effect of conservative therapy on LSS, a minority of the patients ultimately require surgery. Surgery for LSS aims to decompress the narrowed spinal canals with preservation of spinal stability. Traditional open surgery, either pure decompression or decompression with fusion, was considered effective for the treatment of LSS with or without DS. However, the long-term clinical outcomes of traditional open surgery are still unclear. Moreover, the disadvantages of conventional open surgery are extensive, examples including tissue injuries or secondary instability, with limited outcomes and significant reoperation rates. With the development and improvement of surgical tools, various minimally invasive spine surgery (MISS) methods, including indirect decompression techniques of interspinous process devices (IPDs) and direct decompression techniques such as microscopic spine surgery or endoscopic spine surgery (ESS), have been updated with enhancement. IPDs, such as Superion devices, were reported to behave with comparable physical function, disability, and symptoms outcomes to laminectomy decompression. As an emerging technique of MISS, ESS has beneficial hallmarks including minimal tissue injuries, reduced complication rates, and shortened recovery periods, thus gaining popularity in recent years. ESS can be classified in terms of endoscopic hallmarks and approaches. Predictably, with the continuous development and gradual maturity, MISS is expected to replace traditional open surgery widely in the surgical treatment of LSS associated with DS in the future.

Keywords: Decompression; Degenerative spondylolisthesis; Endoscopic spine surgery; Interspinous process devices; Lumbar spinal stenosis; Lumbar spine; Minimally invasive spine surgery.

Fig. 1

Schematic lumbar spinal stenosis associated with degenerative spondylolisthesis and open laminectomy decompression surgery. Sagittal (a) and axial (b) images depict the pathologic compression of the cauda equina and/or nerve roots. Schema (c) shows the surgical area of traditional open laminectomy decompression technique

Fig. 2

Schema of the surgical procedure of unilateral laminotomy for bilateral decompression surgical technique. a The operating table is tilted to the opposite side of the surgeon. With the aid of endoscope or microscope, the vision of bilateral visual fields behind the dura mater in the spinal canal is achieved; b tools are utilized to decompress the spinal canal on the exposed side of the surgical incision; c “over-the-top” technology is adapted to decompress the contralateral side

Fig. 3

Two surgical approaches of endoscopic spine surgery. a The transforaminal approach, referring to a posterolateral percutaneous approach to the disc or epidural space via the foraminal window while preserving the normal musculoskeletal structures, usually under local anesthesia; b the interlaminar approach, similar to open laminectomy decompression or microscopic spine surgery, usually under general or epidural anesthesia

Fig. 4

Key surgical steps of the transforaminal full-endoscopic lumbar undercutting laminectomy technique. a Working cannula is installed as the first step with subsequent whole removal of the superior articular process (colored in red); b undercutting laminectomy and ventral half resection of the inferior articular process (colored in red); c partial removal of the thickened ligamentum flavum (colored in red); d the narrowed spinal canal is enlarged following the TE-LUL surgery

Fig. 5

Categories of the endoscopic system for endoscopic spine surgery. a Percutaneous endoscopic or full-endoscopic system. A working channel endoscope contains a working channel and an optical device within a single portal, which needs continuous saline irrigation for normal working; b microendoscopic system with the optical device attached to the tubular retractor, without needing constant saline irrigation during surgery; c biportal endoscopic system with separate endoscopic working and viewing channels, in need of continuous saline irrigation when operating