Sang Chul Lee MD1, Ricardo Ruiz-Lopez MD, FIPP2, and Won Joong Kim MD3 1 Seoul National University, Seoul, South Korea Despite a paucity of studies examining the mechanical compression of nerve roots in lumbar foraminal spinal stenosis (LFSS), it has been assumed that LFSS results in damage to microvascular structures and continuous compression of nerve roots, subsequently causing ischemia, edema, demyelination, and C-fiber hyperactivation [1, 2]. One hypothesis of the physiopathology in LFSS is that numerous lumbar foraminal ligaments cause low back pain and radiculopathy [3, 4]. Lumbar foraminal ligaments fix the lumbosacral spinal nerves to the intervertebral foramen and protect the nerve and blood vessels from being damaged. However, if abnormal adhesion or too many foraminal ligaments exist, they may result in pain through compression of the nerve root [5]. To achieve effective decompression of LFSS by resecting foraminal ligaments, and to facilitate the spread of medication around the target nerve, specially designed instruments for percutaneous lumbar extraforaminotomy (PLEF) was invented to allow a minimally invasive procedure. The boundaries of the foramen contain two mobile joints – intervertebral disc (IVD) and zygapophyseal joints. The boundaries are: Structures in the intervertebral foramen are: Lumbar foraminal ligaments are composed of the following ligaments [6–8] (Figure 65.1): Figure 65.1 Schematic drawing of ligaments in the lumbar neural foramen. 1 = superior corporotransverse ligament; 2 = inferior corporotransverse ligament; 3 = superior transforaminal ligament; 4 = middle transforaminal ligament; 5 = inferior transforaminal ligament; 6 = posterior transforaminal ligament [9]. Percutaneous Extraforaminotomy (PLEF) provides advantages as a Minimally Invasive Spine Technique: There are two specially designed instruments to implement PLEF. 1) Instrument consisting of (Figures 65.2 and 65.3): Figure 65.2 Specially designed instruments for the percutaneous lumbar extraforaminotomy procedure [9]. Figure 65.3 Disposable set for PLEF (Park®). After 8–10 ml of 0.5% lidocaine was administered at the intended needle entry tract, a 15 cm, 16G Tuohy needle is inserted under anteroposterior fluoroscopic guidance. In the lateral fluoroscopic view, the needle tip is advanced until it is located at the posterior part of the borderline between the IAP and SAP. An epidurogram is then obtained after injection of 5 ml contrast to confirm that the needle is placed in the epidural space and to avoid intravascular or subarachnoid needle placement. Then, the Tuohy needle is withdrawn slightly to the level of the facet joint capsule. Subsequently, a trocar is inserted adjacent to the Tuohy needle and the Touhy needle is removed. Next, a cannula is inserted through the trocar to guide an end mill, which ultimately replaces the trocar. Finally, the end mill is placed within the epidural space in the intervertebral foramen. In the next step, the end mill is removed and a curette is introduced through the cannula while maintaining the bevel of the curette facing to the ventral side to avoid any neurovascular injury (Figure 65.4a–d). Figure 65.4 Fluoroscopic images during lumber extraforaminotomy procedures. (a) Entry point of the needle is 12–14 cm away from the midline of the vertebral body. (b) In the lateral fluoroscopic view, the cannula tip is advanced until it is located at the posterior part of the borderline between the inferior and superior articular processes. (c) A distraction of the foraminal ligament and mechanical adhesiolysis are performed by the curette through the cannula until the tip of the curette reaches the medial border of the pedicle in the anteroposterior fluoroscopic image. (d) Postadhesiolysis epidurogram is obtained before injecting local anesthetics and corticosteroids [9] (Figure 65.5). Figure 65.5 Needle trajectory to the intervertebral foramen by a posterolateral approach. The needle is advanced to the target foramen while avoiding any injury to the internal organs [9]. 2) Instrument consisting of ( Figure 65.6): Figure 65.6 Specially designed instrument for the percutaneous lumbar extraforaminotomy procedure [10].
65
Complications of Percutaneous Lumbar Extraforaminotomy
2 Clinica Vertebra, Spine and Pain Surgery Centers, Barcelona / Madrid, Spain
3 Pain and Rehabilitation Clinic, Fort Lee, NJ, USA
Introduction
Anatomy
Indications
Contraindications
Technique
![](https://clinicalpub.com/wp-content/uploads/2023/09/256.png)
Full access? Get Clinical Tree
![](https://videdental.com/wp-content/uploads/2023/09/appstore.png)
![](https://videdental.com/wp-content/uploads/2023/09/google-play.png)