Evolving Role of Lumbar Decompression: A Narrative Review

Sagar Telang; Sahil S. Telang; Ryan Palmer; Andy Ton; William J. Karakash; Jonathan Ragheb; Siddharth Patel; Jeffrey C. Wang; Ram K. Alluri; Raymond J. Hah

doi:10.14444/8702

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Table 1

Summary features of lumbar decompression techniques.19–32

Procedure	Summary Features
Laminectomy	Indications ● Symptomatic spinal canal stenosis that does not respond to conservative treatment ● Rapidly progressing neurological deficits or intolerable pain ● Cauda equina syndrome
	Contraindications ● Patients with multiple medical comorbidities including depression ● Scoliosis ● Spondylolysthesis ● Lateral listhesis
	Approaches ● Open
	Advantages ● High success rate with significant alleviation of preoperative symptoms ● Low rate of postoperative complications that continues to reduce with the implementation of less invasive approaches
	Disadvantages ● Potential iatrogenic disruption of posterior structures and anatomy/biomechanics of spine ● May require concomitant fusion
Laminoplasty	Indications ● Symptomatic stenosis without any signs of significant instability
	Contraindications ● Severe osteoporosis or active infection ● Significant instability requiring fusion
	Approaches ● Open
	Advantages ● Posterior spinal structures preserved ● Reduced risk of postoperative spinal instability and deformity
	Disadvantages ● Limited literature looking at long-term outcomes of lumbar laminoplasty compared to other procedures ● Greater risk for nerve root injury intraoperatively ● Longer operative time
Laminotomy	Indications ● Spinal stenosis with neurological symptoms ● Multilevel spondylotic lateral canal stenosis ● Lateral recess stenosis secondary to disc herniation
	Contraindications ● Severe instability necessitating fusion ● Pan-canal or central stenosis ● Severe facet joint arthritis or osteoporosis
	Approaches ● Open, minimally invasive, endoscopic (includes inside-out, outside-in, contralateral techniques) ● Unilateral and bilateral
	Advantages ● Reduced risk for iatrogenic mechanical instability and prolonged recovery when compared to laminectomy ● Superior preservation of posterior spinal structures
	Disadvantages ● Limited extent of decompression when compared to laminectomy ● May not fully alleviate central canal stenosis
Foraminotomy	Indications ● Foraminal stenosis with compression of neural structures
	Contraindications ● Severe spinal instability (e.g., scoliosis, spondylolisthesis, kyphosis) necessitating fusion ● Significant neurological deficits requiring more extensive decompression ● Active infection or severe osteoporosis
	Approaches ● Open, minimally invasive, endoscopic (includes transforaminal and laser assisted endoscopic foraminotomies)
	Advantages ● Preserves lamina integrity ● Potential postoperative improvement of both foraminal diameter and height
	Disadvantages ● Risk of nerve injury ● Reduced access to central canal leading to potential risk for incomplete decompression and symptom recurrence
Percutaneous Minimally Invasive Lumbar Decompression (MILD)	Indications ● Stenosis secondary to ligamentum flavum hypertrophy ≥2.5 mm ● Typically reserved for patients with multiple medical comorbidities making them high-risk candidates for traditional procedures
	Contraindications ● Previous spinal surgery ● Infection at the site of potential surgery
	Approaches ● Percutaneous approach through a small incision ● Performed utilizing local anesthesia with the assistance of fluoroscopic guidance
	Advantages ● Is safe for patients with comorbidities that make it challenging to tolerate traditional spinal surgery such as laminectomy and laminotomy ● Does not require general anesthesia ● Minimally invasive, avoiding large incisions and lamina removal
	Disadvantages ● Limited decompression compared to traditional surgical method ● Limited evidence and literature available showing long-term efficacy

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Table 2

Summary features of endoscopic lumbar decompression.22,24,64,76–92

Procedure	Summary Features
Endoscopic Microdiscectomy	Indications ● Lumbar disc herniation resulting in neurological deficits and radiculopathy not responding to conservative management
	Contraindications ● Severe facet joint arthritis or active infection ● Severe central canal stenosis requiring extensive decompression than provided by microdiscectomy
	Approaches ● Interlaminar or Transforaminal
	Advantages ● Reduced soft tissue and bony trauma ● Smaller incision and improved visualization of the surgical site ● Shorter LOS in hospital and faster recovery
	Disadvantages ● Steep learning curve ● Potential for limited access to complex herniations or multi-level diseases increasing risk of incomplete decompression
Transforaminal Endoscopic Lumbar Foraminotomies (TELF)	Indications ● Foraminal stenosis with nerve root compression ● Lateral recess stenosis caused by disc herniation
	Contraindications ● Necessity for more extensive decompression due to severe central canal stenosis ● Severe facet joint arthritis or active infection
	Approaches ● Transforaminal
	Advantages ● Improved visualization of neural structures along with smaller incisions resulting in reduced soft tissue trauma ● Enhanced preservation of structures around surgical site and improved postoperative spinal stability
	Disadvantages ● Reduced access to central canal ● Challenging to achieve full decompression in severe cases of foraminal stenosis
Endoscopic Unilateral Laminotomy for Bilateral Decompression (ULBD)	Indications ● Symptomatic disc herniation not responding to conservative management ● Lumbar spinal stenosis resulting in bilateral neural compression
	Contraindications ● Severe central canal stenosis requiring more invasive approaches to achieve adequate decompression ● Significant spinal instability such as vertebral fractures or severe spondylolisthesis ● Severe facet joint arthritis or active infection
	Approaches ● Typically interlaminar
	Advantages ● Preservation of contralateral structures due to unilateral approach for bilateral decompression ● Smaller incisions, reduced soft tissue trauma, quicker recovery, and shorter in hospital LOS
	Disadvantages ● Steep learning curve ● Limited access to central canal