Given the current lack of high-quality research, it is challenging to recommend specific treatment modalities for elderly patients with lumbar spinal stenosis (6). Therefore, We propose a stepwise approach to treatment, including conservative, interventional, and surgical interventions. For patients with mild symptoms, conservative treatments such as medication, physiotherapy, and exercise therapy are recommended (7). Exercise therapy is currently recommended as the first-line treatment for lumbar spinal stenosis (8). This includes lumbar flexion and extension exercises, core stability training, bicycle training, body-weight supported treadmill training (BWSTT), aquatic exercises, among other exercise therapies. Some researchers suggest using epidural steroid injections to alleviate symptoms of neurogenic claudication, although robust evidence supporting their long-term effectiveness is currently lacking.Steroid injections can also assist surgeons in accurately identifying the affected intervertebral gap, thus providing a diagnostic basis for surgical intervention. Patients with moderate to severe neurogenic claudication may benefit from decompression surgery. The goal of laminectomy decompression is to remove part or all of the lamina to create additional space within the spinal canal, thereby alleviating pressure on the dural sac nerve roots. Due to its relative conservative approach and lower complication rate, it is a preferred surgical option for the elderly (9).However, traditional laminectomy decompression surgery may lead to damage to the posterior lumbar muscle structure, particularly the multifidus muscle. The subsequent loss of innervation and fat infiltration may be associated with chronic lower back pain and failed back surgery syndrome (10). As a result, there has been a shift in focus towards minimally invasive surgical techniques.
Minimally invasive surgery can effectively mitigate muscle and soft tissue damage, thus reducing intraoperative bleeding, easing postoperative pain, shortening postoperative bed-rest duration, and lowering the average hospital stay. Owing to its unique benefits like long operative corridors, visualization technology, and ability to perform procedures under local anesthesia, endoscopic technology is superior to traditional open surgery, particularly for high-risk patients with spinal degenerative diseases, such as the elderly and obese individuals. Reports indicate that the intervertebral foramen approach in treating lumbar spinal stenosis has achieved commendable results (11).Minimally invasive spinal surgeries using full endoscopic techniques present challenges for conditions other than herniated discs, such as spinal stenosis. Among various techniques for treating lumbar spinal stenosis, the interlaminar approach for central stenosis is considered reasonable, as opposed to the transforaminal technique. The results of this meta-analysis indicate that in patients with primary neurogenic claudication without instability or previous surgery, adequate decompression via an interlaminar approach using full endoscopic techniques can achieve good clinical outcomes(12, 13). However, due to factors such as limited visualization of the surgical field and operational skill, it's challenging to achieve complete decompression of the lateral recess and contralateral dorsal nerve root in the spinal canal, which still limits the utilization of this technique. The development of minimally invasive instruments, including powered drills and visualized ring saws, The development of minimally invasive instruments, including powered drills and visualized ring saws, enables easier decompression of the posterior lamina ligament structure and hypertrophic joints, thus making it feasible to perform unilateral approach for bilateral decompression. In this study, decompression was performed along the insertion and origin of the ligamentum flavum between the laminae, simplifying the surgeon's task in defining the range of decompression and delineating the surgical path, This approach reduces the risks of incomplete decompression, dural sac injury, and nerve root injury due to unclear anatomical relationships under direct visualization.
Surgical interventions are inevitably come with potential complications. As per existing literature, the most prevalent complications include persistent postoperative pain, rupture of the dural sac, the necessity for spinal revision surgery due to recurrence, and instability induced by excessive resection of facet joints [13-14]. In our cohort, one case of dural sac injury was recorded,likely due to the dura mater adhering to the ligamentum flavum. To prevent adverse outcomes, deep suturing and pressure bandaging were employed postoperatively.Overall, our study highlights the efficacy and safety of endoscopic interlaminar decompression as a minimally invasive therapeutic option for lumbar spinal stenosis, particularly in elderly patients. While surgical interventions carry inherent risks, advancements in surgical techniques and careful attention to surgical details can help mitigate these risks and improve patient outcomes.