Lumbar spinal canal and foraminal stenosis (LSCS) has long been considered a simple ‘degenerative’ disease, despite the recent discovery of a genetic predisposition, related to a catalase enzyme deficit in the ligamentum flavum, as the key factor for developing the disease.

Professor Luigi Manfrè is Chair of the Spine Neuroradiology Committee of the European Society of Neuroradiology (ESNR), and Head of the Spine Interventional NR Department at the Institute of Oncology for Mediterranean IOM, Viagrande, in Catania, Italy.

People suffering from LSCS typically experience neurogenic claudication and reduced walking autonomy due to burning pains in the buttock and lower limb. Considering the elderly age of patients, all these symptoms have a negative impact on their quality of life.

When a conservative approach fails, conventional open surgery like laminectomy is generally adopted, with or without posterior fixation for decompression and stabilisation. Nevertheless, a very aggressive treatment performed under general anaesthesia cannot be considered the ideal solution for older patients.

During the last ten years, a new minimally invasive approach to the disease has been found, using percutaneous interspinous devices (PID), which has quickly become an alternative, less invasive technique. The biomechanical concept is to insert a spacer between two adjacent spinous processes, using coaxial muscle dilators, under the guidance of angiography or CT. Minimally invasive and percutaneously inserted PIDs are no less effective than conventional surgery in terms of outcomes and failure, but have several advantages as there is a dramatic reduction of operating times (approximately just ten minutes), definitely less blood loss, and no need for general anaesthesia, as analgo-sedation is sufficient to perform all the treatment.

If LSCS is considered a disease typical for older patients, painful microinstability is one of the most frequent pain generators and causes of chronic low back pain (LBP) in young adults, particularly related to spine load stress (sporting activity, jobs that place stress on the spine, etc.). When conservative treatment fails, and no definite results occur after zygoapophyseal nerve radio-ablation or cryo-ablation, percutaneous transfacetal fixation (TFF) is an excellent option to cure these patients, without affecting the flexibility of the spine and allowing sporty people to maintain even competitive activity.

Interspinous percutaneous spacers: a 10mm spacer is introduced between the L4–L5 spinous processes.

The procedure consists of introducing two trocar needles under local anaesthesia, passing through the facet joint, and inserting a mini-screw via coaxial guidewire, that can fix the joint, preventing the excessive movement generated by the instability. The use of a combination of CT and C-arm guided procedure is essential for the precise placement of the screws, as the optimal result depends on the right position of the devices. Recent biomechanical tests demonstrated the TFF to be equivalent to conventional surgical posterior fixation (PIF), but it is less aggressive, as a single 10mm incision is generally performed under local anaesthesia only.

Transfacetal screw micronisation al L5–S1 level.

Spinal interventional neuroradiology with the use of CT-guided techniques is again revealed to be an affordable winning choice in terms of saving time, reducing side effects, and providing a powerful minimally invasive surgical treatment.