Anatomic MIS Treatment-based classification of spinal
motion-segment disease and application in Endoscopically-
assisted lamino-foraminoplasty
Said G Osman, M.D., F.A.A.O.S., F.R.C.S.Ed.(ortho)
Frederick, Maryland USA
BACKGROUND
1. Lack of a universal comprehensive treatment-based classification
• When a vehicle breaks down the necessary part is ordered using a catalogue number (universal code) for that part. When the part is fixed, the vehicle, almost invariably is cured!
BACKGROUND
1. Lack of a universal comprehensive treatment-based classification
• The diagnosis of back problem is much more complicated than that of vehicular breakdown! But it is desirable to have “ Universal Codes” which can guide treatment options!
BACKGROUND
Why is universal comprehensive treatment-based classification desirable?
1. Multiple anatomic structures contributing to pain at each spine level,
2. Advanced imaging technology identifies each pathologic entity
3. Medical professionals across the globe will be able to accurately developments
4. It makes comparison of outcome studies of different treatment options more accurate and relevant
BACKGROUND
Recent opinions about how to treat this case:
o Classify the disease, Facet block, discography, then decide based on patient-specific data
o Facet block L5-S1
o Discography then endoscopy
o Radiofrequency anuloplasty + caudal block.
o mechanical percutaneous annuloplasty
o AxiaLIF as ALIF through paracoccygeal approach
o More data and axial views, good discography and treatment with STALIF L5/S1 or ADR L5/S
o Artificial disc replacement if not, comfortable posture & walking traction( vertetrack)& standing extension excersise trial to rebalancing between psoas & extensors 1st. Then consider annuloplasty.
BACKGROUND
o Why so many opinions?
Based on the clinical information and MRI findings:
1. Each doctor probably had arrived at a differentdiagnosis; or
2. Some may have arrived at same diagnosis butrecommended different options.
Differences of opinion aremeaningful if we agree onthe diagnosis (or if we have a Universal code tolabel the disease!)
BACKGROUND
2. Emergence of sophisticated diagnostic tools:
oMRI scan:
oDisc
oAlignment
oFacet joint
oLigamentum
oCanal dimensions
oCT scan
oWithout contrast
oCT-mylelogram
o3D images
BACKGROUND
4. Emergence of multiple treatment modalities:
oDiscectomy:
oOpen interlaminar
oTubular interlaminar
oEndoscopic interlaminar:
oUniportal
oBiportal, unilateral vs bilateral
oEndoscopic transforaminal
oUniportal
oBiportal
oEndoscopic trans-iliac
oFusions:
oOpen: Posterolateral, PIF, TLIF, ALIF
oMIS: PLIF, TLIF, LLIF, OLIF,
oEndoscopically assisted: KLIF, ETIF, Trans-osseous interbody fusion
oDisc arthroplasty
oPosterior dynamic stabilization
PURPOSE
To develop a comprehensive treatment-based
classification of spinal motion-segment disease
METHODS
o Review of literature
o Grading of the pathology of intervertebral disc, facet joint, ligamentum flavum, and spinal column alignment
o Development of a matrix with all the SMS components
o Computation of all possible combinations of SMS grading
o Retrospective study of the prevalence of the combination in clinical situation.
METHODS
o Grading of the pathology of intervertebral
disc, facet joint, ligamentum flavum, and
spinal column alignment
A = Alignment D = Disc F = Facet L = Ligamentum Flavum (LF)
A0 = NormalA1= RetrolisthesisA2 = Grade I spondyA3 = Grade 2SpondyA4= Grade III & IVspondy w/o synovialcyst formation
D0 = Normal discD1 = Global bulging discD2 = ContainedherniationD3 = Free frag herniationD4 = Disc osteophytesposterior
F0 = Normal facetF1 = IAP hypertrophyF2 = SAP hypertrophyF3 = IAP & SAP hypertrophyF4 = IAP & SAP hypertrophy & synovial cyst.
Key:IAP = Inferior Articular ProcessSAP = Superior Articular Process
L0 = NormalL1= Minimal hypertrophy ofLFL2= Moderate hypertrophyof the LFL3= Severe hypertrophy ofthe LFL4 = Calciified/ossified
RESULTS
: a: normal alignment (A0); b – retrolisthesis (A1); c – grade 1 spondylolisthesis (A2); d
– grade II spondylolisthesis (A3); e – grade III & IV spondylolisthesis (A4)
RESULTS
: a – normal disc (D0); b – global bulge (D1); c – intra-annular disc herniation (D2);
d – extra-annular disc herniation (D3); and e – posterior disc osteophytes (A4).
RESULTS
a – normal facet (F0); b – inferior articular process hypertrophy (F1); c- superior
articular process hypertrophy (F2); d - inferior and superior process hypertrophy
(F3); e – facet hypertrophy and synovial cyst formation (F4)
RESULTS
normal LF (L0); b – mildly hypertrophied LF (L1); c – moderately hypertrophied (L2); d
– severely hypertrophied LF (L3); d - calcified LF (L4)
METHODS Development of a matrix with all the SMS components
D0
(normal disc)
D1
(global bulge)
D2
(Intra-annular
herniation)
D3
(Extra-annular
herniation)
D4
(Disc
osteophytes)
F0
(Normal facet = normal foraminal height & AP
diameter)
D0A0L0F0 DI A0L1F0 D2A0L2FO D3A0L3F0 D4A0L4F0
A0
(Normal alignment)
F1
(IAP hypertrophy = ↓ lat recess AP diameter)
D0L0A0F1 D1L1A1F1 D2A1L2F1 D3A1L3F1 D4A1L4F1
A1
(Retrolisthesis = ↓ disc height, global bulge )
F2
(SAP hypertrophy = ↓ foraminal height & AP
diameter)
D0A2L0F2 D1A2L1F2 D2A2L2F2 D3A2L3F2 D4A2L4F2
A2
(Grade I listhesis = Mild to moderate central and
foraminal stenosis)
F3
(S&IAP hypertrophy = ↓ Foraminal height &
foraminal/lat recess AP diameter)
D0A3L0F3 D1A3L1F3 D2A3L2F3 D3A3L3F3 D4A3L4F3
A3
(Grade II listhesis = moderate to severe central & foraminal
stenosis)
F4
(S&IAP hyper + cyst =↓ foraminal, height &
foraminal/lat recess ±central AP diameter)
D0A4L0F4 D1A4L1F4 D2A4L2F4 D3A4L3F4 D4A4L4F4
A4
(Grade III&IV listhesis = extreme central and foraminal stenosis)
L0
(normal LF)L1
(mild LF hypertrophy)
L2
(moderate LF hypertrophy)
L3
(severe LF hypertrophy)
L4
(Calcified, hypertrophied LT
RESULTS 494 Possible Combinations
BASIC DISC CODE STANDARDIZED DISC CODE BASIC ALIGNMENT CODE STANDARDIZING ALIGN CODE BASIC LIG CODE STANDARD LIG CODE BASIC FACET CODE STANDARD FACET CONE
D0A0L0F0 D001 D0A0L0F0 A001 D0A0L0F0 L001 D0A0L0F0 F001
D0A0L1F0 D002 D1A0L1F0 A002 DIA0L0F0 L002 D0A1L0F0 F002
D0A0L2FO D003 D2A0L2FO A003 D2A0L0FO L003 D0A2L0F0 F003
D0A0L3F0 D004 D3A0L3F0 A004 D3A0L0F0 L004 D0A3L0F0 F004
D0A0L4F0 D005 D4A0L4F0 A005 D4A0L0F0 L005 D0A4L0F0 F005
D0A0L0F1 D006 D0A0L0F1 A006 D0A0L0F1 L006 DI A0L1F0 F006
D0A1L1F1 D007 D1A0L1F1 A007 D1A1L0F1 L007 D1A1L1F0 F007
D0A1L2F1 D008 D2A0L2F1 A008 D2A1L0F1 L008 D1A2L1F0 F008
D0A1L3F1 D009 D3A0L3F1 A009 D3A1L0F1 L009 D1A3L1F0 F009
D0A1L4F1 D010 D4A0L4F1 A010 D4A1L0F1 L010 D1A4L1F0 F010
D0A2L0F2 D011 D0A0L0F2 A011 D0A2L0F2 L011 D2A0L2F0 F011
D0A2L1F2 D012 D1A0L1F2 A012 D1A2L0F2 L012 D2A1L2F0 F012
D0A2L2F2 D013 D2A0L2F2 A013 D2A2L0F2 L013 D2A2L2F0 F013
D0A2L3F2 D014 D3A0L3F2 A014 D3A2L0F2 L014 D2A3L2F0 F014
D0A2L4F2 D015 D4A0L4F2 A015 D4A2L0F2 L015 D2A4L2F0 F015
D0A3L0F3 D016 D0A0L0F3 A016 D0A3L0F3 L016 D3A0L3F0 F016
D0A3L1F3 D017 D1A0L1F3 A017 D1A3L0F3 L017 D3A1L3F0 F017
D0A3L2F3 D018 D2A0L2F3 A018 D2A3L0F3 L018 D3A2L3F0 F018
D0A3L3F3 D019 D3A0L3F3 A019 D3A3L0F3 L019 D3A3L3F0 F019
D0A3L4F3 D020 D4A0L4F3 A020 D4A3L0F3 L020 D3A4L3F0 F020
D0A4L0F4 D021 D1A0L1F4 A021 D0A4L0F4 L021 D4A0L4F0 F021
D0A4L1F4 D022 D2A0L2F4 A022 D1A4L0F4 L022 D4A1L4F0 F022
D0A4L2F4 D023 D3A0L3F4 A023 D2A4L0F4 L023 D4A2L4F0 F023
D0A4L3F4 D024 D4A0L4F4 A024 D3A4L0F4 L024 D4A3L4F0 F024
D0A4L4F4 D025 D0A1L0F0 A025 D4A4L0F4 L025 D4A4L4F0 F025
D1A0L0F0 D026 DI A1L1F0 A026 D0A0L1F0 L026 D0A0L0F1 F026
D1A0L1F0 D027 D2A1L2F0 A027 DI A0L1F0 L027 D0L0A1F1 F027
D1A0L2F0 D028 D3A1L3F0 A028 D2A0L1F0 L028 D0A2L0F1 F028
D1A0L3F0 D029 D4A1L4F0 A029 D3A0L1F0 L029 D0A3L0F1 F029
D1A0L4F0 D030 D0A1L0F1 A030 D4A0L1F0 L030 D0A4L0F1 F030
D1L0A0F1 D031 D1A1L1F1 A031 D0L1A0F1 L031 DI A0L1F1 F031
D1L1A1F1 D032 D2A1L2F1 A032 D1L1A1F1 L032 D1L1A1F1 F032
D1A1L2F1 D033 D3A1L3F1 A033 D2A1L1F1 L033 D1A2L1F1 F033
D1A1L3F1 D034 D4A1L4F1 A034 D3A1L1F1 L034 D1A3L1F1 F034
D1A1L4F1 D035 D0A1L0F2 A035 D4A1L1F1 L035 D1A4L1F1 F035
D1A2L0F2 D036 D1A1L1F2 A036 D0A2L1F2 L036 D2A0L2F1 F036
D1A2L1F2 D037 D2A1L2F2 A037 D1A2L1F2 L037 D2A1L2F1 F037
D1A2L2F2 D038 D3A1L3F2 A038 D2A2L1F2 L038 D2A2L2F1 F038
D1A2L3F2 D039 D3A1L3F2 A039 D3A2L1F2 L039 D2A3L2F1 F039
D1A2L4F2 D040 D4A1L4F2 A040 D4A2L1F2 L040 D2A4L2F1 F040
D1A3L0F3 D041 D0A1L0F3 A041 D0A3L1F3 L041 D3A0L3F1 F041
D1A3L1F3 D042 D1A1L1F3 A042 D1A3L1F3 L042 D3A1L3F1 F042
D1A3L2F3 D043 D2A1L2F3 A043 D2A3L1F3 L043 D3A2L3F1 F043
D1A3L3F3 D044 D3A1L3F3 A044 D3A3L1F3 L044 D3A3L3F1 F044
D1A3L4F3 D045 D4A1L4F3 A045 D4A3L1F3 L045 D3A4L3F1 F045
D1A4L0F4 D046 D0A1L0F4 A046 D0A4L1F4 L046 D4A0L4F1 F046
D1A4L1F4 D047 D1A1L1F4 A047 D1A4L1F4 L047 D4A1L4F1 F047
D1A4L2F4 D048 D2A1L2F4 A048 D2A4L1F4 L048 D4A2L4F1 F048
D1A4L3F4 D049 D3A1L3F4 A049 D3A4L1F4 L049 D4A3L4F1 F049
D1A4L4F4 D050 D4A1L4F4 A050 D4A4L1F4 L050 D4A4L4F1 F050
D2A0L0F0 D051 D0A2L0F0 A051 D0A0L2F0 L051 D0A0L0F2 F051
D2A0L1F0 D052 D1A2L1F0 A052 D1A0L2F0 L052 D0L0A1F2 F052
D2A0L2F0 D053 D2A2L2FO A053 D2A0L2F0 L053 D0A2L0F2 F053
D2A0L3F0 D054 D3A2L3F0 A054 D3A0L2F0 L054 D0A3L0F2 F054
D2A0L4F0 D055 D4A2L4F0 A055 D4A0L2F0 L055 D0A4L0F2 F055
D2L0A0F1 D056 D0A2L0F1 A056 D0A0L2F1 L056 DI A0L1F2 F056
D2L1A1F1 D057 D1A2L1F1 A057 D1A1L2F1 L057 D1A1L1F2 F057
D2A1L2F1 D058 D2A2L2F1 A058 D2A1L2F1 L058 D1A2L1F2 F058
D2A1L3F1 D059 D3A2L3F1 A059 D3A1L2F1 L059 D1A3L1F2 F059
D2A1L4F1 D060 D4A2L4F1 A060 D4A1L2F1 L060 D1A4L1F2 F060
D2A2L0F2 D061 D0A2L0F2 A061 D0A2L2F2 L061 D2A0L2F2 F061
D2A2L1F2 D062 D1A2L1F2 A062 D1A2L2F2 L062 D2A1L2F2 F062
D2A2L2F2 D063 D2A2L2F2 A063 D2A2L2F2 L063 D2A2L2F2 F063
D2A2L3F2 D064 D3A2L3F2 A064 D3A2L2F2 L064 D2A3L2F2 F064
D2A2L4F2 D065 D4A2L4F2 A065 D4A2L2F2 L065 D2A4L2F2 F065
D2A3L0F3 D066 D0A2L0F3 A066 D0A3L2F3 L066 D3A0L3F2 F066
D2A3L1F3 D067 D1A2L1F3 A067 D1A3L2F3 L067 D3A1L3F2 F067
D2A3L2F3 D068 D2A2L2F3 A068 D2A3L2F3 L068 D3A2L3F2 F068
D2A3L3F3 D069 D3A2L3F3 A069 D3A3L2F3 L069 D3A3L3F2 F069
D2A3L4F3 D070 D4A2L4F3 A070 D4A3L2F3 L070 D3A4L3F2 F070
D2A4L0F4 D071 D0A2L0F4 A071 D0A4L2F4 L071 D4A0L4F2 F071
D2A4L1F4 D072 D1A2L1F4 A072 D1A4L2F4 L072 D4A1L4F2 F072
D2A4L2F4 D073 D2A2L2F4 A073 D2A4L2F4 L073 D4A2L4F2 F073
D2A4L3F4 D074 D3A2L3F4 A074 D3A4L2F4 L074 D4A3L4F2 F074
D2A4L4F4 D075 D4A2L4F4 A075 D4A4L2F4 L075 D4A4L4F2 F075
D3A0L0F0 D076 D0A3L0F0 A076 D0A0L3F0 L076 D0A0L0F3 F076
D3A0L1F0 D077 DI A3L1F0 A077 D1A0L3F0 L077 D0L0A1F3 F077
D3A0L2F0 D078 D2A3L2FO A078 D2A0L3FO L078 D0A2L0F3 F078
D3A0L3F0 D079 D3A3L3F0 A079 D3A0L3F0 L079 D0A3L0F3 F079
D3A0L4F0 D080 D4A3L4F0 A080 D4A0L3F0 L080 D0A4L0F3 F080
D3L0A0F1 D081 D0L0A3F1 A081 D0L3A0F1 L081 DI A0L1F3 F081
D3A1L1F1 D082 D1A3L1F1 A082 D1A1L3F1 L082 D1L1A1F3 F082
D3A1L2F1 D083 D2A3L2F1 A083 D2A1L3F1 L083 D1A2L1F3 F083
D3A1L3F1 D084 D3A3L3F1 A084 D3A1L3F1 L084 D1A3L1F3 F084
D3A1L4F1 D085 D4A3L4F1 A085 D4A1L3F1 L085 D1A4L1F3 F085
D3A2L0F2 D086 D0A3L0F2 A086 D0A2L3F2 L086 D2A0L2F3 F086
D3A2L1F2 D087 D1A3L1F2 A087 D1A2L3F2 L087 D2A1L2F3 F087
D3A2L2F2 D088 D2A3L2F2 A088 D2A2L3F2 L088 D2A2L2F3 F088
D3A2L3F2 D089 D3A3L3F2 A089 D3A2L3F2 L089 D2A3L2F3 F089
D3A2L4F2 D090 D4A3L4F2 A090 D4A2L3F2 L090 D2A4L2F3 F090
D3A3L0F3 D091 D0A3L0F3 A091 D0A3L3F3 L091 D3A0L3F3 F091
D3A3L1F3 D092 D1A3L1F3 A092 D1A3L3F3 L092 D3A1L3F3 F092
D3A3L2F3 D093 D2A3L2F3 A093 D2A3L3F3 L093 D3A2L3F3 F093
D3A3L3F3 D094 D3A3L3F3 A094 D3A3L3F3 L094 D3A3L3F3 F094
D3A3L4F3 D095 D4A3L4F3 A095 D4A3L3F3 L095 D3A4L3F3 F095
D3A4L0F4 D096 D0A3L0F4 A096 D0A4L3F4 L096 D4A0L4F3 F096
D3A4L1F4 D097 D1A3L1F4 A097 D1A4L3F4 L097 D4A1L4F3 F097
D3A4L2F4 D098 D2A3L2F4 A098 D2A4L3F4 L098 D4A2L4F3 F098
D3A4L3F4 D099 D3A3L3F4 A099 D3A4L3F4 L099 D4A3L4F3 F099
D3A4L4F4 D100 D4A3L4F4 A100 D4A4L3F4 L100 D4A4L4F3 F100
D4A0L2F0 D101 D0A4L0F0 A101 D0A0L4F0 L101 D0A0L0F4 F101
D4 A0L2F0 D102 D1A4L1F0 A102 D1A0L4F0 L102 D0L0A1F4 F102
D4A0L3FO D103 D2A4L2F0 A103 D2A0L4FO L103 D0A2L0F4 F103
D4A0L3F0 D104 D3A4L3F0 A104 D3A0L4F0 L104 D0A3L0F4 F104
D4A0L4F0 D105 D4A4L4F0 A105 D4A0L4F0 L105 D0A4L0F4 F105
D4A1L0F1 D106 D0A4L0F1 A106 D0A0L4F1 L106 D1A0L1F4 F106
D4A1L2F1 D107 D1A4L1F1 A107 D1A1L4F1 L107 D1A1L1F4 F107
D4A1L3F1 D108 D2A4L2F1 A108 D2A1L4F1 L108 D1A2L1F4 F108
D4A1L3F1 D109 D3A4L3F1 A109 D3A1L4F1 L109 D1A3L1F4 F109
D4A1L4F1 D110 D4A4L4F1 A110 D4A1L4F1 L110 D1A4L1F4 F110
D4A2L0F2 D111 D0A4L0F2 A111 D0A2L4F2 L111 D2A0L2F4 F111
D4A2L2F2 D112 D1A4L1F2 A112 D1A2L4F2 L112 D2A1L2F4 F112
D4A2L3F2 D113 D2A4L2F2 A113 D2A2L4F2 L113 D2A2L2F4 F113
D4A2L3F2 D114 D3A4L3F2 A114 D3A2L4F2 L114 D2A3L2F4 F114
D4A2L4F2 D115 D4A4L4F2 A115 D4A2L4F2 L115 D2A4L2F4 F115
D4A3L0F3 D116 D0A4L0F3 A116 D0A3L4F3 L116 D3A0L3F4 F116
D4A3L2F3 D117 D1A4L1F3 A117 D1A3L4F3 L117 D3A1L3F4 F117
D4A3L3F3 D118 D2A4L2F3 A118 D2A3L4F3 L118 D3A2L3F4 F118
D4A3L3F3 D119 D3A4L3F3 A119 D3A3L4F3 L119 D3A3L3F4 F119
D4A3L4F3 D120 D4A4L4F3 A120 D4A3L4F3 L120 D3A4L3F4 F120
D4A4L0F4 D121 D0A4L0F4 A121 D0A4L4F4 L121 D4A0L4F4 F121
D4A4L2F4 D122 D1A4L1F4 A122 D1A4L4F4 L122 D4A1L4F4 F122
D4A4L3F4 D123 D2A4L2F4 A123 D2A4L4F4 L123 D4A2L4F4 F123
D4A4L3F4 D124 D3A4L3F4 A124 D3A4L4F4 L124 D4A3L4F4 F124
D4A4L4F4 D125 D4A4L4F4 A125 D4A4L4F4 L125 D4A4L4F4 F125
RESULTS
o Review of MRI Films:
o 204 Spinal motion-segments
o 57 patients
o Male = 30, Female = 27
o Age range; 16 to 87 years (Mean = 47.3 yrs)
RESULTS
Review of MRI Films:
CODE % Pathologic
D0A0L0F0 33.3 Normal disc, normal alignment, normal ligamentum flavum, normal facet joint
D1A0L0F0 8.8 Degenerative global bulging disc, normal alignment, normal LF, and normal facet joint
D2A0L0F2 6.9 Intra-annular disc herniation, normal alignment, normal LF, and hypertrophy of superior articular
process
D1A0L1F3 6.4 Global bulging disc, normal alignment, mild hypertrophY LF, hypertrophic superior & inferior
articular processes
D1A0L1F0 3.9 Global disc bulge, normal alignment, mild hypertrophy of LF, normal facet joint
D2A0L1F0 2.5 Intra-articular disc herniation, normal alignment, mild hypertrophy of LF,
D3A0L0F0 2.5 Extra-annular disc herniation, normal alignment, normal LF, normal facet joint
D1A0L0F3 2 Global disc bulge, normal alignment, normal LF, Superior and inferior articular processes
D1A1L0F0 2 Global disc bulge, retrolisthesis, normal LF, normal facet joint.
D2A0L0F3 2 Intra-discal herniation, normal alignment, normal LF, Superior and inferior articular processes
D2A0L1F3 2 Intra-annular herniation, normal alignment, mild LF hypertrophy, superior and inferior process
hypertrophy
D1A1L1F1 3 Global disc bulge, retrolisthesis, mile LF hypertrophy, superior and inferior process hypertrophy
D1A2L1F3 3 Global disc bulge, grade I spondylolisthesis, mild LF hypertrophy, superior and inferior process
hypertrophy
Clinical Application of the Classification System.
o Case # 1:
o 57 year old male with 3 year old low back pain and increasing
radicular pain and weakness in the left lower extremity. Back pain
was 3/10, leg pain 7/10,
o SLR = 20 degrees on left, Tibialis Anterior strength = 2/5, EHL = 2/5,
and EHL = 3/5. Leg pain and weakness got worse over 6 weeks
pre-operatively.
o MRI showed D3A0L1F3 at L4-5. Patient had endoscopic
interlaminar discectomy, and laminoplasty/foraminoplasty using
Endo-Flex system.
Clinical Application of the Classification System.
Case # 1: Pre-op MRI study:
o D1A0L2F3
Foraminotomy vs laminectomy and partial facetectomy.
(Transforaminal and Posterior Decompression of the Lumbar Spine – A Comparative Study of Stability and Intervertebral Foraminal Area. Spine, 22 #15:1690-1697.)
Endoscopic Foraminoplasty:
o 1. 45.5% increase in the intervertebralforaminal area
o 2. There was no flexibility change
o 3. Minimal anatomic damage to the spine.
Laminectomy and medial-third facetectomy:
o 1. 34.2% increase in the intervertebralforaminal area
o 2. Significant increase in extension andaxial rotation flexibility
o 3. Structural compromise – posteriorligaments, spinous process, laminae andfacets
Endoscopic Lamino-foraminoplasty and Discectomy
IO-Flex system - Amendia
Endoscopic Lamino-foraminoplasty and Discectomy
IO-Flex system - Amendia
Endoscopic Lamino-foraminoplasty and Discectomy
• D1A0L3F3
Endoscopic Lamino-foraminoplasty and Discectomy
o Ipsilateral Interlaminar Approach:
o Debulk ligamentum flavum and stay extra-canal
o Debride/burr IAP to enter lateral recess
o Perform discectomy – if necessary
Endoscopic Lamino-foraminoplasty and Discectomy
o Ipsilateral Interlaminar Approach:
o Discectomy
Endoscopic Lamino-foraminoplasty and Discectomy
o Passage of Endo-Flex wire medio-laterally
Endoscopic Lamino-foraminoplasty and Discectomy
o Endo-Flex lamino-foraminoplasty
Endoscopic Lamino-foraminoplasty and Discectomy
o Contra-lateral Endo-Flex lamino-foraminoplasty
Endoscopic Lamino-foraminoplasty and Discectomy
o Bilateral Endo-Flex lamino-foraminoplasty + Transforaminal discectomy
Clinical Application of the Classification System.
Case # 1: Intra-perative.
o Placement of
ipsilateral Endo-flex
wire and lamino-
foraminoplasty with
microblade.
Clinical Application of the Classification System.
Case # 1: Intra-perative.
o Placement of
contralateral Endo-
flex wire and lamino-
foraminoplasty with
microblade.
Clinical Application of the Classification System.
Case # 1: Intra-perative.
o Application of the Endoflex for
endoscopic lamino-
foraminoplasty.
Clinical Application of the Classification System.
CONCLUSION
• Comprehensive treatment-based SMS Classification is feasible
• Many combinations have no clinical relevance
• 33.3% of the studied cohort are normal SMS
• The most prevalent diseased SMS is degenerated and globally bulging disc without facet, alignment or LF abnormality
• Treatment-based classification is clinically applicable and reproducible.
• The Treatment-based classification can be used to compare outcomes of different treatment options
• The large clinically relevant combinations will need software development for quick reference and choice of treatment options