1. Lumbar stenosis case (MT-ULBD)
Case for plenary or small group discussions
MISS Curriculum Taskforce
Roger Härtl
July 1, 2019
2019 and 2020

2. Learning objectives
Describe the indications and how to select the correct patient
Discuss the decision-making process for the specific procedure
Outline important aspects of performing the procedure
Recognize possible complications and how to avoid and manage them

3. Presentation
82-year-old woman presents with tingling and burning sensation in her legs when standing and walking
Develops heaviness and buttock and bilateral leg pain when she walks; she can only walk a few blocks
Sitting down relieves the pain
No mechanical back pain with flexion and extension
Past medical history: Coronary artery disease with stents, on blood thinners, medication controlled diabetes mellitus, otherwise healthy
Neurological examination: intact, vascular examination normal (pulses)
Discuss the exam of the patient: /what do you do in the office and what do you ask for?
How to differentiate between different types of pain: radicular, mechanical and neurogenic claudication. What maneuvers do you perform when you examine the patient? Rule our hip and knee pathology, check pulses etc.
Stationary bike: no problem. Denies bowel or bladder problems.
Diagnosis: vascular claudication without mechanical back pain

4. Imaging R foramen Left foramen Discuss imaging:
DDD, grade I spondylolisthesis L4/5 and L5/S1, disc collapsed, facet angle L4/5 relatively high (steep), no foraminal stenosis
Discuss indication of other imaging: CT, scoliosis films, CT myelogram, F/E films etc.

5. Previous treatment 3 months of physical therapy
Had 2 epidural injections within last year with transient pain relief
Saw 2 other surgeons and wants to discuss surgical options
Failed nonoperative treatments

6. Flexion/extension films
No movement

7. Diagnosis L4/5 spondylolisthesis and stenosis Neurogenic claudication
Failed nonoperative treatments

8. Management plan/options
Nonoperative treatment
Physical therapy, pain management
Surgery
Interspinous spacer
Laminectomy
Open vs MIS tubular: ULBD
Endoscopic
Decompression and fusion
MIS TLIF
LLIF
OLIF
Others?

9. Treatment L4/5 MIS laminectomy (right side incision/ULBD)
Discuss positioning, OR set up
How to localize

10. “Over the top” contralateral decompression
Key is to achieve a good over the top bilateral decompression

11. Outcome Surgery time skin to closure 45 minutes Minimal blood loss
One night in the hospital because of her preoperative morbidities
Neurologically intact after surgery
Postoperative muscle spasms treated with muscle relaxants, subsided after a few days
Walking improved

12. MISS tubular surgical options
MIS tubular microdiscectomy (MCD)
MIS tubular foraminotomy
MIS tubular laminotomy or bilateral laminectomy: ULBD
MIS tubular resection of synovial cyst
MIS tubular fusion (as part of MIS TLIF)
MIS tubular spinal canal tumor resection
These are other indications for tubular decompression

13. Patient selection Patient complaints vs patient imaging Stability
Canal stenosis
Foraminal stenosis (unilaeral and/or bilateral)
Previous surgery

14. Complications Dural tear and cerebrospinal fluid (CSF) leak
Size of leak?
If nerve root exposed it should be reinserted and primary closure considered
May require special needle holder, knot pusher, suture
Neural injury—very rare
In cases with severe stenosis and calcification where the root is manipulated Usually transient weakness
Infection—very rare
Postoperative muscle pain/inflammation
Muscle relaxants, oral steroids sometimes
Meticulous hemostasis
Consider epidural steroids before closure

15. Take-home messages
MIS laminectomy via tubular retractor is safe and effective
Can address bilateral pathology via unilateral approach
Can preserve stability and avoid fusion
Adherence to strict MIS techniques minimizes complications such as CSF leak, neural/vascular injury, infection, etc