Intraoperative Fluoroscopic Verification of Satisfactory Foraminotomy in Posterior Open Decompression Surgery for Lumbar Foraminal Stenosis: A Clinical Image

Abstract

ABSTRACT

Lumbar spinal stenosis (LSS) represents an increasingly encountered disorder in current clinical practice, being unfavorably associated with chronic low back pain, progressive neurologic decline and disability. LSS represents the major etiology for spine surgery in elderly individuals. In the era of continuous development of novel full‐endoscopic techniques, conventional open surgery with decompression of neural elements and with or without fusion of the compromised segment continues to represent the current gold standard for surgical management of these patients. In cases with foraminal stenosis, foraminal decompression with mobilization of the exiting nerve root represents the primary aim of surgery. However, intraoperative proper identification of the extent of decompression may be problematic in specific cases with significantly altered anatomy. The aim of this clinical image is to present a rare case of a patient with symptomatic foraminal stenosis, in which the rate of satisfactory foraminal decompression was intraoperatively verified via routine C‐arm fluoroscopy. To our best knowledge, the utilization of fluoroscopy for verification of the extent of decompression in lumbar foraminal stenosis has never been reported in contemporary literature. Therefore, except for routine localization purposes, intraoperative fluoroscopy may be considered an additional measure to assess foraminal decompression in such cases.

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Summary

• Open decompression surgery with foraminotomy constitutes the primary surgical selection for patients with lumbar foraminal stenosis.
• Intraoperative fluoroscopy may assist in the verification of decompression in selected cases.

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Lumbar Spinal Stenosis (LSS) represents a degenerative condition that is associated with progressive functional compromise of the spinal unit and subsequent compression of the dural sac and nerve roots. Unfavorably, LSS represents the current leading cause of spine surgery in elderly individuals, being associated with multimodal sequelae for affected individuals [1].

Diagnosis of LSS is accomplished via clinical examination and MRI, which represents the diagnostic tool of choice. Surgical treatment is indicated in cases of progressive neurologic deficit or persistent symptoms. In these cases, fluoroscopy represents the cornerstone for the rational conduction of all available surgical techniques [2].

The aim of this study is to describe a unique case of surgically managed lumbar spinal foraminal stenosis, in which satisfactory foraminal decompression was intraoperatively verified via routine fluoroscopy.

A 73-year-old male was presented to outpatient clinics of our Department with chronic drug-resistant sciatica and numbness in the right lower limb, both of L4 nerve root distribution. Past medical history was unremarkable, whereas clinical examination revealed no motor, sensory, or reflex disturbances.

MRI evaluation was indicative of L4–L5 right foraminal stenosis with exiting nerve root impingement (Figure 1A,B). Differential diagnosis was conducted from other miscellaneous etiologies of sciatica as degenerative, inflammatory, infectious, and neoplastic conditions. Considering the chronicity and drug resistance of sciatica, surgical treatment was indicated. Open decompression surgery was decided to be performed over transforaminal endoscopic lumbar discectomy (TELD) since the patient was obese, a status that represents a relative contraindication for the endoscopic procedure [3].

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After routine unilateral L4–L5 interlaminar fenestration, foraminotomy with exiting nerve root mobilization was meticulously conducted. Interestingly, the satisfactory rate of foraminotomy was also intraoperatively fluoroscopically verified (Figure 2A,B). No particular challenges or complications were encountered intraoperatively.

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Patient recovered successfully postoperatively, being uneventfully discharged on the same day. Complete recession of sciatica in conjunction with the return to daily activities was recorded 6 weeks postoperatively.

Despite the rapid development of endoscopic spine surgery in recent years, open decompression techniques are routinely implemented for the surgical management of LSS. Full-endoscopic procedures, and especially TELD, feature specific contraindications except for their advantages associated with their minimal invasiveness [3]. For these reasons, conventional posterior open decompression surgery with or without fusion continues to represent the current gold standard for these patients [1]. In cases with lumbar foraminal stenosis, neurolysis with mobilization of the exiting nerve root post decompression is considered the primary aim. Interestingly, satisfactory decompression may also be roughly verified with conventional intraoperative fluoroscopy especially in cases with abnormal osseous growth as the principal etiology of stenosis, as delineated in our case.

To our best knowledge, this is a unique case in existent literature where satisfactory foraminotomy with exiting nerve root decompression in a patient with lumbar foraminal stenosis was intraoperatively verified via routine C-arm fluoroscopy. Intraoperative fluoroscopy should be considered as an additional intraoperative measure to evaluate the extent of decompression in cases of foraminal stenosis, particularly in individuals with excessive development of intraforaminal osseous alterations resulting in exiting nerve root impingement.

Author Contributions

Stylianos Kapetanakis: conceptualization, data curation, investigation, methodology, supervision, visualization, writing – original draft, writing – review and editing. Joanna Bladowska: data curation, formal analysis, investigation, methodology, supervision, writing – review and editing. Paschalis Tsioulas: data curation, formal analysis, supervision, writing – review and editing. Georgios Tsolakidis: data curation, investigation, methodology, writing – original draft. Christos Siopis: data curation, investigation, methodology, supervision, writing – review and editing. Nikolaos Gkantsinikoudis: conceptualization, data curation, formal analysis, investigation, methodology, visualization, writing – original draft.

Acknowledgments

The authors have nothing to report.

Consent

Written informed consent of the patient was obtained for submission and publication of this Clinical Image.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data regarding this Manuscript are not available at any public repository and has not been previously presented anywhere but is available upon reasonable request.

References

Z. Liang, X. Xu, X. Chen, Y. Zhuang, R. Wang, and C. Chen, “Clinical Evaluation of Surgery for Single‐Segment Lumbar Spinal Stenosis: A Systematic Review and Bayesian Network Meta‐Analysis,” Orthopaedic Surgery 14, no. 7 (2022): 1281–1293, [DOI: https://dx.doi.org/10.1111/os.13269].