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Image-Guided Percutaneous Lumbar Decompression For The Treatment of Symptomatic Lumbar Spinal Canal Stenosis 2011

Interventional Spine

Orlando, Ortiz, MD, MBA
Amanjit, Baadh, MD, Non ASSR Member

Poster

Purpose

To show the efficacy and safety of image-guided percutaneous lumbar decompression (PLD) in the treatment of symptomatic lumbar spinal canal stenosis

Methods & Materials

Image-guided PLD was performed in 9 consecutive patients. 5 patients were female and 4 patients were male with an average age of 64 years (Range 65 to 83 years of age). All patients presented with 8 to 10 out of 10 midline low back pain that was associated with bilateral lower extremity pain and weakness. All patients had MRI studies that showed severe spinal canal stenosis at one, and rarely 2, levels of the lumbar spine. The L4-5 level was affected in 7 of the 9 patients; 3 patients had L3-4 involvement; 2 patients had involvement at L3-4 and L4-5. Each procedure was performed by a single operator using intravenous anesthesia with strict aseptic technique and pre-procedure intravenous antibiotic prophylaxis. An epidurogram was performed at the level below the stenosis in all patients using fluoroscopic guidance and modified loss of resistance technique with a 22 gauge Whitacre needle that was connected by extension tubing to a contrast (Omnipaque 240) containing syringe. The level(s) of stenosis were confirmed in all patients prior to proceeding with PLD. PLD was performed either via a unilateral approach (6 patients) or a bilateral approach (3 patients). 2% local Lidocaine was administered along the intended treatment trajectory to the external surface of the lumbar lamina. Following a small dermatotomy, a 6 gauge portal needle was advanced to the external surface of the lamina with a lateral to medial approach near the midline. A laminotomy was performed with a 7 gauge bone rongeur and small fragments of the superficial and intermediate layers of hypertrophied ligamentum flavum were carefully resected under fluoroscopic monitoring. The endpoint for resection was relief of the stenosis as evidenced by free flow of epidural contrast agent through and above the level of stenosis. An epidural steroid injection (with 3 mL 0.5% Bupivicaine and 2 mL (80 mg) methylprednisolone) was administered through the previously place Whitacre needle and the patient was recovered. All patients were followed for a period of at least 3 months, with a maximum follow-up at 2 years.

Results

All patients experienced significant reductions in their numeric pain scores, of a least 5 units, with 5 patients reporting no pain at 3 weeks, 3 months and 1 year follow-up. All patients noted an improvement in their ability to ambulate a distance of at least 1 block. The first patient that was treated and followed at 2 years remains without pain and has resumed her activities of daily living. All patients noted significant reductions in analgesic use. No complications were encountered in this group of patients.

Conclusion

Image-guided PLD is a safe and effective treatment for patients with symptomatic lumbar spinal canal stenosis. Patients report significant improvements with respect to pain reduction, resumption of activities of daily living and reduction of analgesic use. With imaging guidance, the procedure can be performed safely.

References/Financial Disclosures

Deer TR, Kapural L. New image-guided ultra-minimally invasive lumbar decompression method: the mild procedure. Pain Physician 2010;13:35-41 Financial Disclosures: Dr. Ortiz: Orthovita, Speakers Bureau

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