Answer to the Letter to the Editor of Hue Zhang concerning “A less invasive surgical approach in the lumbar lateral recess stenosis: direct approach to the medial wall of the pedicle” by A. Colak et al. (2008) Eur Spine J; 17:1745–1751

Excerpt

The surgical techniques directed to lateral recess stenosis are in tendency of being less invasive compared to the traditional spinal stenosis surgical methods that are applied for regular decompression. The aim is decompressing the stenotic area with the least destruction in the anatomy that contributes to stability. Almost all described techniques have common hallmark of facetectomy. Although to what degree the facetectomy must be performed is not delineated clearly, the suggested amount of medial facetectomy ranges from one-third to one-half [1, 2]. Indeed, nobody can be sure of the quantity of facetectomy made without a CT scan. When deciding which patients would benefit from lateral recess decompression alone, preoperative CT scans should be evaluated together with the MR images. When the lateral recess stenosis is accompanied by canal narrowing of more than 50 % and remarkable hypertrophy of the yellow ligament is discerned in MR images, decompressing the lateral recess alone will neither satisfy the surgeon in regards to effective canal decompression nor the patient in terms of pain relief and enhancement to the quality of life after the operation. Another point that is to consider in addition to effectively releasing the neural tissue in the stenosis segment is preserving the alignment and stability of the spinal column subject to decompression. Instability risk that might emerge during operation when you have to remove more bony structures to achieve effective decompression should not be underestimated. In aging spinal column, even little angles of scoliosis and rotational deformities of the posterior elements of the vertebrae and the degenerative changes in the bone and capsule components of the facet joints may compress dura and roots. Although you design your surgical plan to remove minimal part of the inferior articular process for facet joint, you may end up with removing more than half of it or even sometimes dropping the facet. Degenerative changes and ineffective remodeling of the bone tissue comprising the facet joint make it too weak to bear any load. As you proceed cranially on vertebral column, both the long axes of the upper lumbar spine pedicles and the facet joint planes are oriented more parallel to the sagittal plane. That means, mostly the inferior articular process of the superior vertebra will undergo facetectomy where superior articular process of the lower vertebra will usually undergo very little facetectomy or remain untouched. The eaves-like spur formation in the medial wall of the pedicle that usually extends to and narrows the neural foramen is removed, and it affects lower vertebra and caudal part of its superior articular projection. …