Minimally invasive alternatives in the treatment of lumbar stenosis

Traditional laminectomy remains a popular technique and is still the 'gold standard' in spine surgical textbooks for lumbar spinal canal stenosis. We believe this technique is far too destructive and is based on a misunderstanding of the pathoanatomy (ie, that all the posterior elements need to be removed to afford decompression) and visualization (ie, all this is needed to see things adequately). The perpetuation of this procedure likely stems from a quite justifiable aversion by well-trained spinal surgeons to minimally invasive techniques. The limited adoption and short life span of most such techniques (eg, laser disectomy, percutaneous suction) can be explained by the fact that although they result in minimal tissue destruction and improved cosmesis, they failed to get the job done safely and thoroughly. Two major developments have altered the way we approach lumbar decompressive surgery. First, MRI has allowed a millimeter by millimeter delineation of the areas of bony and soft tissue compression responsible for each patient's neurological symptoms, thereby significantly improving our understanding of the pathoanatomy and allowing us to address only these areas of compression during surgery. Second, the operative microscope has provided superior visualization and illumination, thereby eliminating the need for large incisions, wide soft tissue elevation and retraction, and bony unroofing. The two operative techniques described here afford minimal destruction of tissues not directly involved in the pathological process, while providing excellent surgical outcomes in well-controlled, prospective studies carried out by independent assessors using validated outcome measures.