---
title: 'Endoscopic lateral recess decompression in a patient with pars defects'
type: 'lecture'
url: 'https://doc.social/lectures/endoscopic-lateral-recess-decompression-in-a-patient-with-pars-defects'
published: '2022-08-13'
author: 'Domingo Molina IV, MD'
specialty: 'Orthopaedic Surgery'
topics: 'Neurological Surgery'
transcript: 'yes'
---

# Endoscopic lateral recess decompression in a patient with pars defects

## Summary

Dr. Molina demonstrates the diagnosis of a complex radiculopathy in a patient with pars defects at L5/S1 with spondylolisthesis. Endoscopic L4/5 lateral recess decompression.

## Transcript

3,984 words · 23 min · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:03] Hi, I'm Dr. Domingo Molina, and I'm an orthopedic Spine surgeon.
[0:07] Hey, everyone, Doctor Molina here again. Uh, today, we have a pretty interesting case. It's a 52-year-old male with right Hip Pain. Uh, patient does not endorse any left leg Pain. Uh, and he also endorses Pain only in the right Hip area. It doesn't radiate down the leg or to the foot. He uses a cane for balance at times, failed conservative measures, uh, no Other neuro exam findings, no upper motor neuron signs. Uh, strength is good. Uh, he's a veteran. Um, I comment on the fact that he's a veteran, uh, because I like to.
[0:36] Kind of evaluate, um, the patient that I'm dealing with, um, whether they're employed, um, what their hobbies are, what kind of goals they're trying to get back to.
[0:46] And uh this helps me diagnose, uh, you know what the problem is, um, in most cases.
[0:55] So we'll move forward through the MRI here, look at this area of kind of uh bony protrusion here at the uh facet joint.
[1:03] And so I'll scroll through the sagittal, you'll see that he does have stenoticfrain at the L5-S1 level. And so you kind of wonder, is this gonna be the issue? Um, the patient doesn't have any Pain on the left side. And so as you scroll through the axle, you'll see here the increased hypertrophic was set on the right side, causing a lot of recescess and those of the L5 nerve. And so, I really thought that this was the patient's Pain generator. Uh, some of this is nerve stress due to the Spondylolisthesis, uh, but I think a lot of it, especially on the sagittal view.
[1:31] Is bony stenosis, um, of the traversing L5 nerve root. And so, I kind of came to this conclusion when patient was only complaining of right Hip Pain and, um, also didn't fully, um, travel down the leg, and he had no Pain on the left side.
[1:46] So we indicated a hemilamminotomy and decompression of that lateral recess.
[1:52] So this is the initial start of our decompression. I'd like to use the pituitary here to, one, obviously remove the superficial layer of the ligamentum flavum. Um, I also like to try to feel around for the bony anatomy, so I'll look for the uh inflateral edge of the L4 lamina, as well as the um superior lateral aspect of the L5 lamina. And so this kind of gives me a, um, a direction of where I'm going, where I'm at.
[2:21] And how far to uh to stray out laterally to start my hammamminotomy.
[2:30] So, of course, I'll make sure I control all the bleeding here. Um, again, I've started, um, as of over the last few months to put Epi into my saline bags. Again, this really does help with, um,
[2:43] Bleeding control and again.
[2:46] I use the RF pro to.
[2:51] Not only control bleeding, but also to use it as a probe to, to check my bony anatomy as well. And so I know here that I'm already kind of at the joint here and I went into this area because I know that, that I have to decompress a lateral recess and, uh, um, and take uh part of the facet joint um laterally. So, so I'm clearing this out, uh, trying to get a feel for, for how far I wanna extend my decompression laterally. Of course, you don't wanna destabilize that segment.
[3:20] And so, I always uh make sure that I use um the dammbu uh to kind of measure how far I'm um decompressing laterally. So I use the punch here also to remove some of those ligamental flavor it's a little bit quicker cause I can just kind of chomp at it.
[3:36] I also like to continue to use the punch uh to to essentially go through the ligamentum flave them to get a.
[3:45] An idea of where I'm at within the spinal canal and so uh you'll see that I'll do that here in a second.
[3:53] It's now we've got
[3:55] Our entrance to the spinal canal, you see the dura there. I'll leave that there and I won't continue to enlarge it cuz I want to protect the dura from the diamond burr when I perform my hemillaminotomy and so, but at least I can assess the uh my location uh of the traversing nerve root.
[4:16] And this will give me an idea of how far I need to decompress laterally.
[4:22] I think it's important to not extend the cranial aspect or the cortical decompression too far laterally. So you'll see that I stopped here, it's approximately, uh, uh, I'd say probably about 5 or 6 millimeters. It's a 4.5 millimeter diamond burr, and so you don't extend it obviously past 8 millimeters, uh, to, to, in order to prevent destabilization of, of that particular level, so.
[4:48] So what I'll do here is I'll kind of extend the cortical uh.
[4:53] Decompression, and then I'll start to uh do the cans portion and, um, and the deeper uh portion of the lateral recess. And so, you saw that I kind of pushed my camera down there. I was wiping the camera, uh, on some of the soft tissue to kinda clean it. Here, I'm removing the tissue around the bone, and this is important because you wanna make sure that you get a good visualization of, of the bone when you're using a burr. Cause if not, then you can umtray into the canal or
[5:22] Um, potentially, you get the tissue wrapped up and it just takes a little bit more time to see what you're doing. So, so here, I've extended the decompression to the, uh, superior lateral aspect of the L5 lamina. You can see some of the joint there. And it's a little bit interesting, right here, right, uh, I'm using pituitary, you can see a little piece of, uh, an osteophyte, and that is essentially what we saw on MRI on the sagittal and axial view.
[5:48] Of that particular bony, um, hypertrophic facet. And so you can see that I didn't separate it from the, um, inferioricular process of L4, and so,
[5:59] Um, this was already, um.
[6:03] Kind of annotated to be an osteophyte that was probably most likely the, the main culprit of uh the patient's radiculopathy. So, I'm just trying to, to move it around here and get an idea of uh the anatomy of the osteophyte. Um,
[6:18] Um, again, trying to remove some of the.
[6:22] Um, lamina, the uh.
[6:25] L5 portion.
[6:29] And so again I'm trying to remove the bone around it as much so I can kind of remove the osteophyte and block.
[6:36] And you can see that the ligamentum is starting to thin out here. So this is probably as much of the decompression. I want to extend caudally. And so, um, you wanna annotate these areas uh when the ligamentum thins out because that's, um, again, kind of a marker to.
[6:55] To give yourself on the location of where you're at within the spinal canal.
[7:02] The curet is a great tool to use during Endoscopic spine surgery. Uh, so here I use the curet to remove some of the, uh, ligamentous attachments to the osteophyte. Again, the dura is right there on the side, so I wanna make sure I remove any adhesions, uh, from the dura to the osteophyte. Um, this can be a little bit dangerous as you wanna make sure that you don't obviously get a dural tear when you're doing this. Um, that's why I kind of come in from the side here.
[7:27] And I try not to essentially pull it too much, but use more of obviously the, the sharp edge of the curre to remove the osteophyte. So you can see here this portion, um.
[7:39] It is moving relatively easy. Uh, and again, I'm gonna start using the pituitary, uh, to try to remove it and block, uh, rather than just chomp at it. Uh, the more you chomp at, obviously, the, the higher risk of dural tear.
[7:55] And so it's easier sometimes to free it up with the curate first and before you go in and use pituitary, essentially, if you use the pituitary, you can also uh pull a big piece of the dir off and that's obviously not favorable, so.
[8:10] Uh, so again, this, uh, is really not gonna fit through the working tube, and so I do have to kind of remove it piecemeal through the working tube, and, uh, and so that's what we do here.
[8:22] So now you can see that the osteophyte is gone. Uh, there's remnants of the cyst down below. Uh, and the reason I call this a cyst is is because I believe that it was a little bit of a combination of a hypertrophic facette as well as a, um,
[8:37] As well as a facet cyst. And so here I can start using the kerosins to remove some of this uh softer kind of cartilaginous um osteophyte. Uh some of it may be kind of good.
[8:51] Uh, kind of cartilaginous, um, facet capsule. And so, um, I also am kind of using the kerosene to free up some of the adhesions from the dura, um, at this area too. So I always make sure that I come in with the kind of shoe with the kerosene back to the dura. Um, I never want to use the sharpen towards the dura. And so I always take ninety-degree bites just obviously, like you would during an open procedure.
[9:18] So again, um, these kerotenes are well made, but again, since they're endoscopic, they're not very strong, and so you can see that superior lateral aspect of the lamina is a little bit thick still. And so, I really try not to waste too much time using the kerossons to get this bone because it's, it's not gonna be fruitful. And so I'll get the small shell.
[9:39] Uh, but then I'll use, um, either a side cutting burr or a diamond burr to really thin out the bone before I start using the kerosene. So, in my mind, the kerosene is usually used for, um, kind of small bony work, um, or any tedious work, uh, that I wanna decompress rather than, than doing it, uh, or using it for the bulk of my decompression.
[10:01] Here we'll start using the side cutting burr, this birr is very aggressive, so you really have to be careful with.
[10:08] Uh, holding on to it because a little straightforward when you start it. And so I use this to extend my decompression laterally. You'll notice that I don't take any cortical bone up high with it. Uh, this is really just to save time on, uh, decompressing a lateral recess.
[10:26] Um I only do it a few seconds at a time to make sure that I'm obviously not straining to the dura and.
[10:34] Removing any soft tissue that that may be in my way.
[10:41] So I switched between this and the diamond burr, as well as the keroans. I'll use the side cutting burr for uh really big pieces of bone in the lateral recesses you can see here, I'm getting a nice decompression with it.
[10:58] Again, I don't wanna use this solely for my entire decompression, uh just due to the risk of dural tear.
[11:12] A lot of times I'm also uh pausing between using a bird to allow the bone dust to, to leave the tube. Again, I don't wanna use the bird when my views obscured.
[11:26] And because uh uh again, that's really where you can get into a lot of trouble.
[11:31] I really take my time with the side cutting burr to decompress the lateral recess. Um, I'm using the kerosene here to retract the dura a little bit, as well as take some bites so I can continue the decompression laterally. And so as you can see, the traversing nerve root is coming into view. I'm trying to assess exactly where the anatomy is, uh, where the traversing nerve root is, what course it's taking. Uh, remember that we have a Spondylolisthesis at L5-S1. So the L5 vertebral body.
[12:01] It's sliding forward, and that's gonna put the traversing nerve root in a different anatomical position than uh the traversing nerve root would normally take. So here, it almost looks like an exiting nerve, uh, but we know that we're at the foramen, so, uh, so we know that's not really possible. So, the reason it looks.
[12:19] Like it's coursing a little bit laterally there, like an exiting nerve root is due to the fact that the uh L5 vertebral body is um listicine.
[12:30] Uh, forward, so.
[12:32] Um,
[12:34] Again, I use the kerosene to remove some of the soft tissue here. Uh, I wanna take a view of the traversing nerve root more caudally. Um, and so this is really what you have to think about when you're doing this is, you know, where exactly the traversing nerve root is, uh, what course it's taking, and, and that ultimately, um, will help you decide, um.
[12:57] Where to decompress. And so here, I'm moving the joint, uh, making sure that one, I'm not destabilizing it. Um, I'm just getting a feel for, uh, the anatomy of the joint. Um.
[13:09] And so I wanna make sure that that I'm really checking all all the anatomical.
[13:14] Um,
[13:16] Con considerations of, of this, uh, decompression. Again, we're really only working within kind of uh 8 to 9, uh, maybe 10 millimeter area here. And so, um, a lot is going on in this area. Uh, you wanna make sure, like I said, that, that you're not decompressing somewhere where you shouldn't, um, or, you know, obviously, decompressing too much. And so, that's why I really am not extending my bony decompression, um, of dorsally.
[13:45] And kind of really kind of extending it, um, eventually, but more laterally. And so, this will, will help stabilize that segment and, um, and obviously not take too much joint. And so, you can see here this, this capsule, um, it's a little bit redundant, and so I'm trying to remove a little bit of that as well. Again, I don't wanna destabilize that capsule too much, um.
[14:11] But I do want to try to remove any soft tissue that I think is potentially impinging that nerve root, so.
[14:19] Another great tool to use is the ball probe, and so, I actually wanna feel the pedicles and make sure that, again, I'm really in the right area. I know that I've stressed this a lot, but this is really um.
[14:33] A very important point of Endoscopic spine surgery, it's very easy to get lost, uh, even when you have a view such as this, and you think you know where everything is at. And so, um, I'm trying to remove any adhesions here, get a feel for the anatomic variation of the traversing nerve root. Um, and sometimes you can see it come off a little bit lower.
[14:54] Sometimes you can see it come off a little bit higher. And so that's really what I'm trying to do here is, is what is the anatomical course of this traversing nerve root. Here, I'm trying to feel the pedicle, um, check the anatomy, cause this is a very, uh, complicated, um.
[15:10] Anatomical spot to work in, especially when you have a pars defects below, below spondylosthesis. Uh, if you remember the MRI, the Spondylolisthesis was greater than 4 or 5 millimeters. So, we know that that traversing nerve roots can be in a different anton position and normally would be.
[15:25] And so, um, again, you wanna control this bleeding fairly quickly, and I'll use the, the RF probe here in a minute, um, to do that, so.
[15:35] Uh, we'll continue with the decompression. You can see that I've already removed some of the bone previously and that traversing nerve root is coming in a little bit more in view. So even though I can see the traversing nerve root somewhat, I do wanna continue the decompression out laterally until I can really know that, um, that traversing nerve root is decompressed. When this patient stands, uh, that foraminal area and it's gonna get smaller. Um, you can see here where the RF probe was, uh, um.
[16:04] That nerve is a little bit erythematous. And so, um, you'll see here once I, uh, open up the lateral recess in a little bit, that this really was the culprit of the patient's radiculopathy due to the irritation of the nerve root. So we've gone through and increased the expansion of a lateral recess with care since. And so, as you can see here, the cortical area up above.
[16:30] Uh, still maintained. Again, I know I keep stressing that, uh, that I'm only decompressing, um, kind of inside out, um, right above the traversing nerve root. Um, again, I'm gonna keep stressing that this is important for stabilization of that segment. So, uh, you can see here that nerve is very erythematous. Um, and so,
[16:54] And, I believe that, again, this is mostly the culprit for that. You can see that I kind of toggled the uh super articular process there. And so, I wanna do this just to make sure that, again, there's no unstable segments. Um, there's not a big piece of bone that I need to, to further evaluate. And so I'm really removing some of this bone that's right over the nerve. Um, and that's gonna be the lateral edge of my decompression.
[17:20] So I'll remove these small fragments here with the kerosene.
[17:24] Again, the L5 nerve root is very tenuous, just like the C5 nerve root and the cervical Spine. So, um, you have to really be careful, uh, to not dig this nerve up too much. Um, so I'm, I'm really cautious of the kerose when I'm taking these bites.
[17:39] Um, so you can see that nerve is just irritated kind of circumferentially. And so I believe the, the stretch of the Spondylolisthesis does cause some of this irritation, but I think it's really the compression against the bone and the osteophyte, uh, that causes it, so.
[17:58] Now we can see here that the nerve is, uh, probably adequately decompressed at this time. I'll remove that kind of caught all, a lip there that it's still, um, traversing under. Uh, you can see there that, that's a good view of uh really the impingement of that bone onto that nerve root. And so, um, this is, uh, a really great example of kind of ultra minimally.
[18:25] Basive decompression of this. Um, could I have done a fusion and a 360 at the L5-S1, um, potentially, but I was worried about that hypertrophic facet and the impingement on the traversing L5 nerve root. So my fear was that if we went with the 361st, uh, that we would potentially still have radiculopathy due to the hypertrophic facet cyst. And I didn't want to entertain a two-level Surgery, uh, when I could potentially just attack the traversing nerve root.
[18:53] And I had counseled the patient that if he didn't get good relief with the endoscopic decompression of the traversing nerve root, then we can move forward with the 360. But at least I would be able to uh provide the decompression of a two-level Surgery endoscopically first. Allow him to heal from that, see what his symptoms are, and then potentially go back and do a 360 later.
[19:16] Do a large cage with indirect decompression and correct the spondylosthesis at, at L5-S1. And so, some people can advocate, well, you could do a 360 and then do this endoscopically at the same time. Um, this took me roughly about an hour. Um, it's not something that I like to entertain.
[19:35] Doing at the same time as a fusion, uh, mostly for logistical reasons and my access surgeon being at a different hospital than my tower. But again, um, if I can do this endoscopic decompression, um, first and get the patient a few years or, you know, whatever length of time that he's pain-free.
[19:55] Um, uh, the spondylosis at L5-S1 looked pretty stable, uh, on flexion extension radiographs. And so, again, if the patient's not having any left leg symptoms and bilateral L5 radiculopathies, it's hard for me to indicate a 360 for just a single, uh, dermatomal, uh, radiculopathy. And so this is why I like to do the endoscopic, uh, decompression for kind of single level or, um, single dermatome, uh, radiculopathy.
[20:24] So you can see here, this is important as I remove these last pieces of bone here along the um lateral recess. Uh, I know that the traversing nerve root is starting to take its exiting course at the L-five pedicle down below. And so, I'm not going to want to, to take too much more bone during my decompression in order to prevent destabilization of that segment. So, you can see here that traversing nerve root is entirely decompressed.
[20:53] It's gonna take a little bit uh for the irritation to subside. So I counsel the patients that you may experience some numbness following the Surgery. Uh, and they may have um some ridiculous symptoms that kind of come and go over the next couple of weeks. Um, I find that this happens sometimes with endoscopic, uh, decompressions. And a lot of times, um, I tell patients, I equate it to like, you know, sitting on your foot and then falling asleep, and then, uh, you're waking up. And so,
[21:21] Uh, once patients know this, they're, they're typically reassured. Uh, before I started to counsel patients on this, I'd always get phone calls about patients stating that they had numbness or still had some conicular radicular pains that happened on and off, and they were somewhat worried about that. And so, um, but they all typically subside after a couple of weeks. So, um, so it's a good thing to tell your patients.
[21:45] And so again, roughly, you know, about a 10 millimeter area of decompression here. Uh, again, you have to take into account that endoscopically, this looks like it's a very large area that's decompressed. Uh, but you, you obviously have to realize you're working through the tube and through the camera, and so everything's magnified. And so, this is what I really love about Endoscopic spine surgery is that this decompression, albeit, um,
[22:12] Somewhat larger through the camera is very small. And, and I've had a couple of patients I've had to take back and do open decompressions uh for separate reasons. And when you go in and see that laminotomy, it's, it's very tiny when you're, when you're extending it during an open procedure. And so, uh, so that's the nice thing about Endoscopic spine surgery.
[22:33] So again, I think we're uh done here with the decompression. I continue to get some of this ligamentum flavm here, but again, I don't spend much time doing that because this is typically where I end up um getting myself into trouble and I don't know when to stop. And so, um, I didn't spend too much more time doing this. And so that's another good, um, aspect of Surgery to really learn and remember, um, as you get into practice is knowing when to stop. And so, the, uh, typically, if I go into these corners, that's when dural tears happen. So, um,
[23:03] So I'm kind of joking my scrub tech right now that this is when I need to stop the decompression.
[23:08] So, uh, thank you for watching this video. I hope you learned a little bit about diagnosis of these kind of more complex, uh, radiculopathies and kind of the treatment options, um, especially using Endoscopic spine surgery.