Foraminoplasty

Foraminoplasty is an aware state endoscopic technique developed by Martin Knight MD, FRCS, MBBS and team about many years ago. It can be used to address many pathologies in the raging spine and also failed back surgery. The aware state feedback helped the medical team to discover the true sources of back pain and has allowed to optimise the treatment at each level. The improved kit now allows to undertake multilevel combination foraminoplasty. The medical team of Dr. M. Knight has now many studies developed in years with results described in specialty literature. In the "Endoscopic Foraminoplasty: A Prospective Study on 250 Consecutive Patients with Independent Evaluation",[1] the conclusion is shown as a minimalist means of exploring the extraforaminal zone, the foramen, the disc, and the epidural space and performing discectomy, lateral recess decompression, osteophytectomy, and neural mobilization with the endoscopic laser foraminoplasty utilised in the aware state. It provides identification and accurate localization of the causal source of pain in multilevel disc disease.

About foraminoplasty

Basically foraminoplasty is a minimally invasive surgery and reduce the patient's pain. In the book "Minimally Invasive Surgery in Orthopedics", Chapter 66 "Endoscopic Foraminoplasty: Key to Understanding the Sources of Back Pain and Sciatica and Their Treatment" (page 535 - 555),[2] M. Knight describe the entire process. The endoscopic laser foraminoplasty is legally regulated.[3] NICE do not fully support it because it has not completed its randomised controlled clinical trial although they admit that most patient benefit from the technique.

History

Foraminoplasty is a term originally coined by the Martin Knight to describe the procedure. The transforaminal intervention was optimized to define the incubus of pain sources and treat discretely or remove the causal pain sources under endoscopic view with the patient in the aware state. In this video material posted by Martin Knight, are shown the clinical outcomes, technique and future development prospects for Foraminoplasty.[4]

Method

Endoscopic Approach

The index level should be targeted first by segmental probing and radiopaque discography. At this stage, the indigo carmine marker dye is inserted in to the disc to distinguish annulus from scar and disc pad.

Once the discography needle has been replaced with the solid guide wire, the standard cannula and dilator are railroaded to the foramen using an oscillating rotating action. Additional local anaesthetic may be needed to secure comfort at the rib margin or iliac crest margin.

When two-dimensional X-rays confirm that the dilator has been placed in the foramen, the standard cannula is replaced with the “Cut Away” slotted cannula, which can more easily be introduced without the curved edges snagging tissues during insertion.

The cannula is attached to the suction Friction Lock Water Seal, the 00 or 200 endoscope is inserted over the guide wire and the position of the guide wire in relation to the exiting nerve root and the facet joint ascertained. With experience, the guide wire is removed once the cannula is in situ.

Foraminal Stage

The foraminal zone consists of a quadrangular space. The superior and inferior notches function as sumps to accommodate the exiting nerve in extension and flexion respectively and ipsilateral and contralateral rotation respectively. These notches become obscured by hypervascular soft tissues and the superior foraminal ligament in the superior notch or by the disc inferiorly. The middle notch becomes narrowed by facet joint hypertrophy, ligamentum flavum infolding and shoulder osteophytes with further compromise due to the tethering of the nerve to the ascending facet or disc.

The fragment may be removed through the large bore endoscope or the endoscope may be removed and the fragments grasped by forward bone graspers and withdrawn through the approach cannula. The raw bone surface is then sealed with the laser to control oozing. This process will provide more space in which to manoeuvre the endoscope. If the cavity of the foramen remains too small, the process can be repeated or additional power reamers and punches may be used. This clearance allows the medial border of the oft flattened and medially displaced nerve root to be clearly visualised and the foramen to be effectively undercut and decompressed.

Further exploration of the superior notch and clearance of the impinging Superior Foraminal Ligament is then undertaken using the laser probe to ablate scar, tethering, the SFL and local facet margin osteophytes until the “functional” axilla is exposed and cleared. Clearance may be supplemented by use of the powered guarded burr and bone punches.

One other method, is the Tessys method, even less painful but surgical.

Advantages

There are several advantages shown by APM Surgery[5] where the developers of this ELF method are mentioned, like M. Knight from UK and D. casper from US.

References

  1. ↑ "Endoscopic Foraminoplasty: A Prospective Study on 250 Consecutive Patients with Independent Evaluation" (PDF): 73–81.
  2. ↑ Minimally Invasive Surgery in Orthopedics (PDF) (2010 ed.). pp. 535–555. ISBN 978-0-387-76607-2.
  3. ↑ "NICE - Server error". nice.org.uk.
  4. ↑ "Development of Transforaminal Endoscopic Spinal Surgery". Martin Knight.
  5. ↑ "Page Title". apmsurgery.com.

External links and literature

This article is issued from Wikipedia - version of the Tuesday, May 19, 2015. The text is available under the Creative Commons Attribution/Share Alike but additional terms may apply for the media files.